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sedation for cataract surgery;monitoring,cases,preop assessment,etc etc
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Importanza dellrsquoanestesista in oftalmologia
DottClaudio Melloni
Libero professionista
Specin Anestesia e Rianimazione
Monitoring
bullSame standards asper ORbullContinuousanestheticsurveillance
Requisites
bull Any unit providing sedation techniques should have the following
bull readily available bull Suitably trained individual to monitor the patient
ndash bull ECG
bull bull Non-invasive blood pressure monitoringbull bull Pulse oximetry
bull etCO2 hellip
bull Further requirements includebull bull The patient should be sedated on a trolley or operating table that can
be tipped head-downbull bull Oxygen should be readily availablebull bull Full resuscitation equipment should be available
ndash LaryngoscopeLMArsquossuctionventilatoretcdrugs(lipids)helliphelliphelliphellip
bull bull The staff looking after the patient should be trained and regularly updated in resuscitation techniques
Oxygen application by a nasal probe prevents hypoxia but not rebreathing of carbon dioxide in patients undergoing eye surgery under
local anaesthesiaSchlager A Luger TJ Br J Ophthalmol 2000 Apr84(4)399-402
New equipment to prevent carbon dioxide rebreathing during eye surgery under retrobulbar anaesthesiaSchlager A Staud H
Br J Ophthalmol 1999 Oct83(10)1131-4
The pursuit of perfection bull Ideas for a perfect matching among surgery
requirements and patient satisfaction and safety
bull Oral antibiotics and sedation ()
bull Topical
bull Microbolus of midaz
bull (Propofol cont infus)
bull Remif microboluses
bull Monitoring NIBPECGSaO2etCO2EEG CSMRamsey
bull isas
Evaluation of recovery aftersedation(+-analgesia)
bull ldquoStreet fitnessrdquo=home discharge
bull Blood pressure stable plusmn 20 basalbull Oxygen saturationplusmn 20 basalbull Pulseplusmn 20 basalbull Mental state plusmn20 (attentionconcentration testetc)bull Equilibriumwalking unassistedbull Ability to dressbull Ability to tolerate oral fluidsbull Absence of bleeding nausea(significant)bull Voiding(mannitolhellip)bull ScoresAldretehellip
bull Easy arousability full orientation (PPT)bull Ability to maintain and protect thebull airwaybull Stable vital signs for at least one hourbull The ability to call for help if necessarybull Ability to unassisted ambulationbull Ability to tolerate oral fluidsbull Ability to void andbull Absence of significant pain or bleeding
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Monitoring
bullSame standards asper ORbullContinuousanestheticsurveillance
Requisites
bull Any unit providing sedation techniques should have the following
bull readily available bull Suitably trained individual to monitor the patient
ndash bull ECG
bull bull Non-invasive blood pressure monitoringbull bull Pulse oximetry
bull etCO2 hellip
bull Further requirements includebull bull The patient should be sedated on a trolley or operating table that can
be tipped head-downbull bull Oxygen should be readily availablebull bull Full resuscitation equipment should be available
ndash LaryngoscopeLMArsquossuctionventilatoretcdrugs(lipids)helliphelliphelliphellip
bull bull The staff looking after the patient should be trained and regularly updated in resuscitation techniques
Oxygen application by a nasal probe prevents hypoxia but not rebreathing of carbon dioxide in patients undergoing eye surgery under
local anaesthesiaSchlager A Luger TJ Br J Ophthalmol 2000 Apr84(4)399-402
New equipment to prevent carbon dioxide rebreathing during eye surgery under retrobulbar anaesthesiaSchlager A Staud H
Br J Ophthalmol 1999 Oct83(10)1131-4
The pursuit of perfection bull Ideas for a perfect matching among surgery
requirements and patient satisfaction and safety
bull Oral antibiotics and sedation ()
bull Topical
bull Microbolus of midaz
bull (Propofol cont infus)
bull Remif microboluses
bull Monitoring NIBPECGSaO2etCO2EEG CSMRamsey
bull isas
Evaluation of recovery aftersedation(+-analgesia)
bull ldquoStreet fitnessrdquo=home discharge
bull Blood pressure stable plusmn 20 basalbull Oxygen saturationplusmn 20 basalbull Pulseplusmn 20 basalbull Mental state plusmn20 (attentionconcentration testetc)bull Equilibriumwalking unassistedbull Ability to dressbull Ability to tolerate oral fluidsbull Absence of bleeding nausea(significant)bull Voiding(mannitolhellip)bull ScoresAldretehellip
bull Easy arousability full orientation (PPT)bull Ability to maintain and protect thebull airwaybull Stable vital signs for at least one hourbull The ability to call for help if necessarybull Ability to unassisted ambulationbull Ability to tolerate oral fluidsbull Ability to void andbull Absence of significant pain or bleeding
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bullSame standards asper ORbullContinuousanestheticsurveillance
Requisites
bull Any unit providing sedation techniques should have the following
bull readily available bull Suitably trained individual to monitor the patient
ndash bull ECG
bull bull Non-invasive blood pressure monitoringbull bull Pulse oximetry
bull etCO2 hellip
bull Further requirements includebull bull The patient should be sedated on a trolley or operating table that can
be tipped head-downbull bull Oxygen should be readily availablebull bull Full resuscitation equipment should be available
ndash LaryngoscopeLMArsquossuctionventilatoretcdrugs(lipids)helliphelliphelliphellip
bull bull The staff looking after the patient should be trained and regularly updated in resuscitation techniques
Oxygen application by a nasal probe prevents hypoxia but not rebreathing of carbon dioxide in patients undergoing eye surgery under
local anaesthesiaSchlager A Luger TJ Br J Ophthalmol 2000 Apr84(4)399-402
New equipment to prevent carbon dioxide rebreathing during eye surgery under retrobulbar anaesthesiaSchlager A Staud H
Br J Ophthalmol 1999 Oct83(10)1131-4
The pursuit of perfection bull Ideas for a perfect matching among surgery
requirements and patient satisfaction and safety
bull Oral antibiotics and sedation ()
bull Topical
bull Microbolus of midaz
bull (Propofol cont infus)
bull Remif microboluses
bull Monitoring NIBPECGSaO2etCO2EEG CSMRamsey
bull isas
Evaluation of recovery aftersedation(+-analgesia)
bull ldquoStreet fitnessrdquo=home discharge
bull Blood pressure stable plusmn 20 basalbull Oxygen saturationplusmn 20 basalbull Pulseplusmn 20 basalbull Mental state plusmn20 (attentionconcentration testetc)bull Equilibriumwalking unassistedbull Ability to dressbull Ability to tolerate oral fluidsbull Absence of bleeding nausea(significant)bull Voiding(mannitolhellip)bull ScoresAldretehellip
bull Easy arousability full orientation (PPT)bull Ability to maintain and protect thebull airwaybull Stable vital signs for at least one hourbull The ability to call for help if necessarybull Ability to unassisted ambulationbull Ability to tolerate oral fluidsbull Ability to void andbull Absence of significant pain or bleeding
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Requisites
bull Any unit providing sedation techniques should have the following
bull readily available bull Suitably trained individual to monitor the patient
ndash bull ECG
bull bull Non-invasive blood pressure monitoringbull bull Pulse oximetry
bull etCO2 hellip
bull Further requirements includebull bull The patient should be sedated on a trolley or operating table that can
be tipped head-downbull bull Oxygen should be readily availablebull bull Full resuscitation equipment should be available
ndash LaryngoscopeLMArsquossuctionventilatoretcdrugs(lipids)helliphelliphelliphellip
bull bull The staff looking after the patient should be trained and regularly updated in resuscitation techniques
Oxygen application by a nasal probe prevents hypoxia but not rebreathing of carbon dioxide in patients undergoing eye surgery under
local anaesthesiaSchlager A Luger TJ Br J Ophthalmol 2000 Apr84(4)399-402
New equipment to prevent carbon dioxide rebreathing during eye surgery under retrobulbar anaesthesiaSchlager A Staud H
Br J Ophthalmol 1999 Oct83(10)1131-4
The pursuit of perfection bull Ideas for a perfect matching among surgery
requirements and patient satisfaction and safety
bull Oral antibiotics and sedation ()
bull Topical
bull Microbolus of midaz
bull (Propofol cont infus)
bull Remif microboluses
bull Monitoring NIBPECGSaO2etCO2EEG CSMRamsey
bull isas
Evaluation of recovery aftersedation(+-analgesia)
bull ldquoStreet fitnessrdquo=home discharge
bull Blood pressure stable plusmn 20 basalbull Oxygen saturationplusmn 20 basalbull Pulseplusmn 20 basalbull Mental state plusmn20 (attentionconcentration testetc)bull Equilibriumwalking unassistedbull Ability to dressbull Ability to tolerate oral fluidsbull Absence of bleeding nausea(significant)bull Voiding(mannitolhellip)bull ScoresAldretehellip
bull Easy arousability full orientation (PPT)bull Ability to maintain and protect thebull airwaybull Stable vital signs for at least one hourbull The ability to call for help if necessarybull Ability to unassisted ambulationbull Ability to tolerate oral fluidsbull Ability to void andbull Absence of significant pain or bleeding
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Oxygen application by a nasal probe prevents hypoxia but not rebreathing of carbon dioxide in patients undergoing eye surgery under
local anaesthesiaSchlager A Luger TJ Br J Ophthalmol 2000 Apr84(4)399-402
New equipment to prevent carbon dioxide rebreathing during eye surgery under retrobulbar anaesthesiaSchlager A Staud H
Br J Ophthalmol 1999 Oct83(10)1131-4
The pursuit of perfection bull Ideas for a perfect matching among surgery
requirements and patient satisfaction and safety
bull Oral antibiotics and sedation ()
bull Topical
bull Microbolus of midaz
bull (Propofol cont infus)
bull Remif microboluses
bull Monitoring NIBPECGSaO2etCO2EEG CSMRamsey
bull isas
Evaluation of recovery aftersedation(+-analgesia)
bull ldquoStreet fitnessrdquo=home discharge
bull Blood pressure stable plusmn 20 basalbull Oxygen saturationplusmn 20 basalbull Pulseplusmn 20 basalbull Mental state plusmn20 (attentionconcentration testetc)bull Equilibriumwalking unassistedbull Ability to dressbull Ability to tolerate oral fluidsbull Absence of bleeding nausea(significant)bull Voiding(mannitolhellip)bull ScoresAldretehellip
bull Easy arousability full orientation (PPT)bull Ability to maintain and protect thebull airwaybull Stable vital signs for at least one hourbull The ability to call for help if necessarybull Ability to unassisted ambulationbull Ability to tolerate oral fluidsbull Ability to void andbull Absence of significant pain or bleeding
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
New equipment to prevent carbon dioxide rebreathing during eye surgery under retrobulbar anaesthesiaSchlager A Staud H
Br J Ophthalmol 1999 Oct83(10)1131-4
The pursuit of perfection bull Ideas for a perfect matching among surgery
requirements and patient satisfaction and safety
bull Oral antibiotics and sedation ()
bull Topical
bull Microbolus of midaz
bull (Propofol cont infus)
bull Remif microboluses
bull Monitoring NIBPECGSaO2etCO2EEG CSMRamsey
bull isas
Evaluation of recovery aftersedation(+-analgesia)
bull ldquoStreet fitnessrdquo=home discharge
bull Blood pressure stable plusmn 20 basalbull Oxygen saturationplusmn 20 basalbull Pulseplusmn 20 basalbull Mental state plusmn20 (attentionconcentration testetc)bull Equilibriumwalking unassistedbull Ability to dressbull Ability to tolerate oral fluidsbull Absence of bleeding nausea(significant)bull Voiding(mannitolhellip)bull ScoresAldretehellip
bull Easy arousability full orientation (PPT)bull Ability to maintain and protect thebull airwaybull Stable vital signs for at least one hourbull The ability to call for help if necessarybull Ability to unassisted ambulationbull Ability to tolerate oral fluidsbull Ability to void andbull Absence of significant pain or bleeding
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
The pursuit of perfection bull Ideas for a perfect matching among surgery
requirements and patient satisfaction and safety
bull Oral antibiotics and sedation ()
bull Topical
bull Microbolus of midaz
bull (Propofol cont infus)
bull Remif microboluses
bull Monitoring NIBPECGSaO2etCO2EEG CSMRamsey
bull isas
Evaluation of recovery aftersedation(+-analgesia)
bull ldquoStreet fitnessrdquo=home discharge
bull Blood pressure stable plusmn 20 basalbull Oxygen saturationplusmn 20 basalbull Pulseplusmn 20 basalbull Mental state plusmn20 (attentionconcentration testetc)bull Equilibriumwalking unassistedbull Ability to dressbull Ability to tolerate oral fluidsbull Absence of bleeding nausea(significant)bull Voiding(mannitolhellip)bull ScoresAldretehellip
bull Easy arousability full orientation (PPT)bull Ability to maintain and protect thebull airwaybull Stable vital signs for at least one hourbull The ability to call for help if necessarybull Ability to unassisted ambulationbull Ability to tolerate oral fluidsbull Ability to void andbull Absence of significant pain or bleeding
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Evaluation of recovery aftersedation(+-analgesia)
bull ldquoStreet fitnessrdquo=home discharge
bull Blood pressure stable plusmn 20 basalbull Oxygen saturationplusmn 20 basalbull Pulseplusmn 20 basalbull Mental state plusmn20 (attentionconcentration testetc)bull Equilibriumwalking unassistedbull Ability to dressbull Ability to tolerate oral fluidsbull Absence of bleeding nausea(significant)bull Voiding(mannitolhellip)bull ScoresAldretehellip
bull Easy arousability full orientation (PPT)bull Ability to maintain and protect thebull airwaybull Stable vital signs for at least one hourbull The ability to call for help if necessarybull Ability to unassisted ambulationbull Ability to tolerate oral fluidsbull Ability to void andbull Absence of significant pain or bleeding
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bull Easy arousability full orientation (PPT)bull Ability to maintain and protect thebull airwaybull Stable vital signs for at least one hourbull The ability to call for help if necessarybull Ability to unassisted ambulationbull Ability to tolerate oral fluidsbull Ability to void andbull Absence of significant pain or bleeding
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Inserimento diapo casistica
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Carla R57 a71 kgASA 2
Mgh
Microgrh
Breathsmin
mmHg
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
0
50
100
150
200
250
300
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microgdiaz 5 mg
Mannitol 18 250
clonid 150 microgrMIDAZ 2 mg
Urapidil 100
NTG 5 mg250 ml
sitt
ing
supine
saline 250 ml
sittingok
V M80 yr70 kg164 cm ASA1(13411)
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
MS53 y85 kg180 cmASA 1(24311)
0
20
40
60
80
100
120
140
160
180
bas 5 10 15 20 25 30
PAS
PAD
FC
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
CO60 yr66 kg163 cmASA 3(Rh arthrtipertensipoacus)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20
PAS
PAD
FC
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
DeG L7177160Asa 2(ipertens)
0
20
40
60
80
100
120
140
160
180
200
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Sergio Al 62 a107 kg199 cmmuratoreASA 1
0
20
40
60
80
100
120
140
160
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8 mg
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
15 03 12 F74kg 68cm 164ASA 2(ipertesa)
0
20
40
60
80
100
120
bas 5 10 15 20 25 30 35 40
PAS
Pad
FC
SaO2
etCO2
Clonid 150+diaz 5pos Midaz 2+ fent 25
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Anna Maria Di S7683 kg157 cmASA1()on statin
0
20
40
60
80
100
120
140
160
180
200
0 10 20 30 35 45 50
PAS
PAD
Fc
SaO2
In sala op
On arrival in preopDiaz mg 5+clonidin 150 microgr p os
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
MBM82kg 75cm 156ASA 3(diabetesobesity)possible difficult
intubation
0
50
100
150
200
250
0 5 10 15 20 30 40 50 60 70
PAS
PAD
Fc
SaO2
Diazepam 5 mg+clonidine 150 mg pos
Visumididriatic 1 gt
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
PPF56 akg50cm 160ASA 1
0
20
40
60
80
100
120
140
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
1555
1555 ini op
Midaz 05
Fent 25 +fent 25
Atropa 05
Midaz 05+fent 25 +fent 25 Midaz 05+midaz 05
DormeRamsey 4 Sveglia
1450clonid 150+diaz 5si addomenta sulla popltrona della presala
Midaz 05+fent 125
Perfalgan 1000
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Paziente anziano che si tira su allrsquoimprovviso bestemmiando quando
il prof lo punge
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Key Components of Risk Associated with Ophthalmic
Anesthesia
Anesthesiology 2006 105859
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Ngozi Imasogie FRCA David T Wong MD Ken Luk BSc Frances ChungFRCPCElimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs A brief report CAN J
ANESTH 2003 50 3 pp 246ndash248
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bull EditormdashI read with interest the closed claims analysis ldquoInjury and
bull Liability Associated with Monitored Anesthesia Carerdquo by Bhananker et al1bull and the accompanying editorial opinion by Hug2 The study indicated thatbull more than one in five monitored anesthesia care claims in the databasebull occurred with patients undergoing elective eye surgery It also reiteratedbull that the most common causes of patient eye injury and anesthesiologistbull liability linked to ophthalmic anesthesia consisted of complications relatedbull to the eye block and perioperative patient movement More than fourbull fifths (83) of ophthalmic anesthesia monitored anesthesia care casesbull associated with inadequate anesthesia andor patient movement eitherbull during the block or intraoperatively resulted in ocular injury and presumablybull poor visual outcome A previous American Society of Anesthesiologistsbull Closed Claims Project ldquoEye Injuries Associated with Anesthesiardquobull by Gild et al3 published in the Journal identified 21 cases of blindnessbull allegedly the result of intraoperative movement during ophthalmic surgerybull Movement was the foremost mechanism of injury cited Five ofbull those claims occurred during regional anesthesia and were attributed tobull ldquorestlessnessrdquo or coughing during the procedurebull Regional anesthesia is a vital part of the scope of anesthesia practicebull Because of its safety and efficacy it is a preferred option for manybull ophthalmic surgical procedures4 Aside from intraoperative analgesia andbull akinesia advantages of conduction anesthesia for ophthalmic surgerybull patients include suppression of the oculocardiac reflex and provision of
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bull Referencesbull 1 Bhananker SM Posner KL Cheney FW Caplan RA Lee LA Domino KBbull Injury and liability associated with monitored anesthesia care A closed claimsbull analysis ANESTHESIOLOGY 2006 104228ndash34bull 2 Hug CC MAC should stand for maximum anesthesia caution not minimalbull anesthesiology care ANESTHESIOLOGY 2006 104221ndash3bull 3 Gild WM Posner KL Caplan RA Cheney FW Eye injuries associated withbull anaesthesia A closed claims analysis ANESTHESIOLOGY 1992 76204ndash8bull 4 Eke T Thompson JR The National Survey of Local Anaesthesia for Ocularbull Surgery II Safety profiles of local anaesthesia techniques Eye 1999 13196ndash204bull 5 Scott IU McCabe CM Flynn HW Jr Lemus DR Schiffman MS Gayer S Localbull anaesthesia with intravenous sedation for surgical repair of selected open globebull injuries Am J Ophthalmol 2002 134707ndash11bull 6 Scott IU Gayer S Voo I Flynn HW Jr Diniz JR Venkatraman A Regionalbull anaesthesia with monitored anaesthesia care for surgical repair of selected openbull globe injuries Ophthalmic Surg Lasers Imaging 2005 36122ndash8bull 7 Grizzard WS Kirk NM Pavan PR Antworth MV Hammer ME Roseman RLbull Perforating ocular injuries caused by anesthesia personnel Ophthalmology 1991bull 981011ndash6bull 8 Hay A Flynn HW Jr Hoffman JI Rivera AH Needle penetration of the globebull during retrobulbar and peribulbar injections Ophthalmology 1991 981017ndash24bull 9 Duker JS Belmont JB Benson WE Brooks HLJr Brown GC Federman JLbull Fisher DH Tasman WS Inadvertent globe perforation during retrobulbar andbull peribulbar anesthesia Patient characteristics surgical management and visualbull outcome Ophthalmology 1991 98519ndash26bull 10 Gayer S Cass G Sub-Tenon techniques should be one option among manybull (letter) ANESTHESIOLOGY 2004 100196bull 11 Miller-Meeks MJ Bergstrom T Karp KO Prevalent attitudes regardingbull residency training in ocular anesthesia Ophthalmology 1994 1011353ndash6
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Sedation risk
bull Disorientationmdashhead movement
bull Restlessnessbull If a patient is unable to tolerate a
blockhellipwould he feel better with sedation
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Eye 1999 Apr13 ( Pt 2)196-204 Comment in Eye 1999 Dec13 ( Pt
6)810-1 The National Survey of Local Anaesthesia for Ocular Surgery II Safety profiles of local anaesthesia techniquesEke T Thompson JRSub-Committee Royal College of Ophthalmologists London UK
bull reported incidence of all adverse events within the orbit 27bull systemic adverse events 09 bull Serious adverse events were reported in association with all LA
techniques
bull 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 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
The Cataract National Dataset electronic multi-centre audit of 55567 operations updating benchmark standards of care in the United Kingdom and internationallyJaycock P Johnston RL Taylor H Adams M Tole DM Galloway P Canning C Sparrow JM UK EPR user groupEye
2009 Jan23(1)38-49 Epub 2007 Nov 23
bull 406 surgeons12 trusts
bull 55567 cataract operations between November 2001 and July 2006 (86 from January 2004)
bull Complication rates
ndash posterior capsule rupture andor vitreous loss 192
ndash simple zonule dialysis 046
ndash retained lens fragments 018
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Risk of eye injury during anesthesia for eye surgery
bull Regional anesthesia technique(USblunt cannulas)
bull Educationexperience
bull Movementscoughing during surgery
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Risk of eye injury during anesthesia for eye surgery databull ASA Closed claim Cheney FW High-severity injuries associated with regional
anesthesia in the 1990s American Society of Anesthesiologists Newsletter 2001656ndash 8
ndash 71 permanent disabling injuries among the 308 claims
ndash 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
ndash Second in frequency (21) were pain-management related claims involving for example neuraxial opiates or neurolytic blocks
ndash Third in frequency (20) were nerve injuries ssociated with neuraxialand peripheral blocks followed by epidural hematomas (13)
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Anesthesiology 2004 101143ndash52Injuries Associated with Regional Anesthesia in the 1980s and 1990sA Closed Claims AnalysisLorri A Lee Karen L Posner Karen B
Domino MPHRobert A CaplanFrederick W Cheney
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Contraindications of localregionalanesthesia
bull Pts unable to cooperate(mentalimpairmentdementiaAlzheimerrsquos)
bull Difficult communication(inability to speak the languagedeafness)
bull Involuntary movementsParkinsonrsquos diseasebull Unable to lie flat or still(CHFCOPD (but chest
uppillowshellip)bull Uncontrolled coughing or sneezingchronic bronchitishellipbull Severely anxious or claustrophobicbull Bilateral surgerybull Prolonged or difficult surgery anticipatedbull Preference for GAwether by the patient or surgeon or
the anesthetisthellip
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Intraocular use of large doses of phenylephrine
bull has been reported to cause severe cardiovascular compromise and possibly death ndash [2 Van der Spek AF Cyanosis and cardiovascular depression in a
neonate Complications of halothane anesthesia or phenylephrineeyedrops 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 subconjunctivalphenylephrine 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 Citation2] [3] [4]
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bull New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room
bull Anesthesiology - Volume 92 Issue 3 (March 2000) -
bull Scott B Groudine MD Ingrid Hollinger MD Jacqueline Jones MD Barbara A DeBounoMD MPHsect
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
The following is a summary of the guidelines circulated to NYS hospitals
bull 1 The initial dose of phenylephrine for adults should not exceed 05 mg (four drops of a 025 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 mildmoderate hypotension This dosage assumes 100 absorption of the administered phenylephrine In children (up to 25 kg) the initial dose should not exceed 20 mugkg [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
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
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
bull
bull 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
bull
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
PONV
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Haloperidol+dexamethasonebull Eur J Anaesthesiol 2010 Feb27(2)192-5
bull Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients a randomized blinded trial
bull Chaparro LE Gallo T Gonzalez NJ Rivera MF Peng PW
ndash 160 high-risk patients undergoing ambulatory surgery(nonsmokingwomen 18 -50 ) cosmetic or ENT surgery
ndash 15 mg of haloperidol 30rsquo before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
author Drugs(microgrkg) POV incidence
Splinter Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter PaediatrAnaesth2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway JPediatr OphtalmolStrabismus 2004
Placebo 645
Ondansetron 150 333
Ondansetron 150+dexamethasone 200 10
Combination antiemetic therapy in paediatric strabismussurgery ondansetron and dexamehasone
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
AnaesthesiaTo be read in conjunction with The Royal College of
OphthalmologistsRoyal College of Anaesthetists guidelineslsquoLocal anaesthesia for intraocular surgeryrsquo
61 Background
bull There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade Thebull use of local anaesthesia (LA) has risen from around 20 in 19911 to over 75 in 19962a and 86 in 19973bull and the use of sedation with LA has fallen from 45 in 1991 to around 6 in 19962abull Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques567bull Most patients presenting for cataract surgery are elderly and have pre-existing medical problems A localbull anaesthetic is preferable particularly for small incision surgery as it will usually be associated with lowerbull morbidity and it causes least disruption to daily routinebull The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adversebull events may occur with all types of LA but are rare (34 per 10000) although a degree of under-reporting wasbull suspected2b These events are not reduced by routine pre-operative investigations89bull No LA technique is totally free of the risk of a serious systemic adverse event This is not necessarily abull consequence of a particular local anaesthetic technique Other factors include pre-existing medical conditionsbull anxiety pain or stress reaction to the operationbull 62 Organisation of ophthalmic anaesthetic servicesbull bull Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of thebull processbull bull Every unit should identify an anaesthetist with overall responsibility for ophthalmic servicesbull bull Meticulous recording of important data is a necessary prerequisite for good communication safe practicebull clinical governance and auditbull 63 Recommending the type of anaesthesiabull The surgical assessment should include recommendations on the type of anaesthetic indicated for thebull individual patient This will depend on psychological aspects the particular features of the globe and orbit andbull the anticipated difficulty of the surgerybull 631 Pre-operative investigationsbull In a randomised survey of over 19000 cataract operations routine pre-operative medicalbull investigations did not reduce the incidence of peri-and post-operative morbidity8bull A previous study in a large teaching hospital showed that even when routine investigations were performedbull the results were rarely taken into account9bull Abull 19bull To quote from the lsquoLocal Anaesthesia for Intraocular Surgery Guidelinesrsquobull ldquoTests should only be considered when the history or a finding on physical examination would have indicatedbull the need for an investigation even if surgery had not been plannedhelliphellipMost abnormalities that would bebull detected on special testing (eg ECG CXR FBC clotting studies urea and electrolytes) can be predicted frombull taking a careful history and performing a physical examination Special tests do not reduce morbidity in thisbull context and are not required unless specifically indicatedhellipFor the patient with no history of significant systemicbull disease and no abnormal findings on examination at the nurse-led assessment no special investigations arebull indicated Any patient requiring special tests may need a medical opinionrdquobull bull Hypertension should be controlled well before the patient is scheduled for surgery and not loweredbull immediately prior to surgerybull bull Angina should be controlled by a patientrsquos usual angina medication which should be available in theatrebull Every effort should be made to make the experience as stress-free as possible Generally patients shouldbull not have surgery within three months of a myocardial infarctbull bull Diabetic patients should have their blood sugar controlled If surgery is planned under LA diabetic patients
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
FINE
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
SCREENING PREOPPATIENTEVALUATION
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Anticoagulants and platelet inhibitors
bull A a study of 19283 cataract surgeries 138 of the 4588 aspirin users and 105 of the 752 warfarin users were advised to stop their aspirin or warfarin before surgery The authors concluded that ldquoThere was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic eventsnor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribedrdquo ndash 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 20031101784ndash8
bull A recent multicentre audit of 55567 cataract operations on patients taking antiplateletand anticoagulant medications concluded that ldquoClopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenonrsquos cannula local anesthesia but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complicationsrdquondash Benzimra JD Johnson RL Jaycock P et al The Cataract National Dataset electronic multicentre audit of 55567
operationsantiplatelet and anticoagulant medications Eye 2008 Feb 8 (Epub ahead of print)
bull It has been estimated that a randomized clinical trial would require 20000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy Often patients are concomitantly
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Jamula E Anderson J Douketis JD
Safety of continuing warfarin therapy during cataract surgery a systematic review and meta-analysis
Thromb Res 2009 Jul124(3)292-9 Epub 2009 Feb 23bull Department of Medicine McMaster University and St Josephs Healthcare Hamilton ON Canadabull Abstractbull 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
bull 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
bull 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 326 95 confidence interval [CI] 173-616) 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
bull 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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
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 surgeryOphthalmology 2003 Dec110(12)2309 Sep110(9)1784-8
bull Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland 21205-2103 USA jkatzjhsphedu
bull OBJECTIVE To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet medication use before cataract surgery
bull DESIGN Prospective cohort study
bull PARTICIPANTS Patients 50 and older scheduled for 19283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997
bull MAIN OUTCOME MEASURES Intraoperative and postoperative (within 7 days) retrobulbarhemorrhage vitreous or choroidal hemorrhage hyphema transient ischemic attack (TIA) stroke deep vein thrombosis myocardial ischemia and myocardial infarction
bull RESULTS Before cataract surgery 242 and 40 of patients routinely used aspirin and warfarin respectively Among routine users 225 of aspirin users and 283 of warfarin users discontinued these medications before surgery The rates of stroke TIA or deep vein thrombosis were 151000 among those who did not use aspirin or warfarin and 381000 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 = 07 95 confidence interval = 01-59) There were no events among warfarin users who discontinued use The rates of myocardial infarction or ischemia were 511000 surgeries (aspirin) and 761000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use
bull 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Eye (Lond) 2009 Jan23(1)10-6 Epub 2008 Feb 8The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medicationsBenzimra JD Johnston RL Jaycock P
Galloway PH Lambert G Chung AK Eke T Sparrow JM EPR User Group
bull Gloucestershire Eye Department Cheltenham General Hospital Gloucestershire Hospitals NHS Foundation Trust Cheltenham Gloucestershire UKbull Abstractbull 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
bull METHODS The Cataract National Dataset was remotely extracted and anonymised on 55567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006
bull RESULTS This report analyses 48862 of the 55567 operations from the eight centres which routinely recorded a drug history In all 281 of the 48862 patients were taking aspirin 51 warfarin 19 clopidogrel and 10 dipyridamole The recording of any complication of a sharp needle or subtenons cannula local anaesthetic block was increased in patients taking clopidogrel 80 (Plt00001) or warfarin 62 (P=00026) vs non-users 43 but no increase in potentially sight-threatening complications was identified The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel 44 (Plt00001) or warfarin 37 (Plt00001) vs non-users 17 The recording of any operative complication was increased in those taking clopidogrel 73 (P=00002) vs non-users 44 but the haemorrhagic operative complications of choroidalsuprachoroidal haemorrhage and hyphaema were not significantly increased The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel 323 (P=00057) vs non-users 177
bull CONCLUSIONS Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenons cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Risks and benefits of anticoagulant and antiplateletmedication use before cataract surgery
Study Operationsnumber
Aspirin warfarin Conclusion
Katz 2003 19283 4588 752 No dif cont vs noncont
Benzimra 2008 55567 9101 1525 Clopidogrel (524 pts)more localrisk
Kobayashi 182+173 Subconjuncthaemorr higherin tnemaintenancegroup
Saumier 229 vs 178 33 + Subconjuncthaemorr (poorstat)
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Ann Fr Anesth Reanim 2010 Dec29(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
bull Pocircle danestheacutesie-reacuteanimation centre hospitalier universitaire dAmiens universiteacute Jules-Verne-de-Picardie avenue Reneacute-Laennec 80054 Amiens cedex France
bull Abstractbull INTRODUCTION cataracts preferentially affect the elderly More than 560000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet andor anticoagulants Haemorrhagic complications resulting from cataract surgery andor eye regional anaesthesia are rare but can lead to serious damage to eye function
bull PATIENTS AND METHODS in this study we compared the management care of two types of antiplatelet andor 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))
bull RESULTS a reference population consisting of 229 patients was operated on exclusively with surgical sub-Tenons 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 Plt005) 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)
bull 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 HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Kobayashi HEvaluation of the need to discontinue antiplatelet and anticoagulant medications before
cataract surgery J Cataract Refract Surg 2010 Jul36(7)1115-9
bull Department of Ophthalmology Kanmon Medical Center Shimonoseki Japan kobiearthocnnejpbull Abstractbull PURPOSE To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
andor anticoagulant treatment in patients having uneventful phacoemulsificationbull SETTING Kokura Memorial Hospital Kitakyusyu Japanbull 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)
bull 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 intraoperativebleeding in any case 47 eyes (165) in the maintenance group and 31 eyes (108) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = 0309) Minor postoperative ocular bleeding occurred in 11 eyes (40) in the maintenance group and 7 eyes (25) in the discontinuation group (P = 4) During the 1-month postoperative period the mean change in corrected distance visual acuity was -0462 logMAR +- 0331 (SD) in the maintenance group and -0434 +- 0318 logMAR in the discontinuation group (P = 3)
bull 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 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
J Cataract Refract Surg 2009 Oct35(10)1815-20Perioperative management of anticoagulated patients having
cataract surgery National audit of current practice of members of the Royal College of Ophthalmologists Batra R Maino A Chng SW
Marsh IBbull Department of Ophthalmology University Hospital Aintree Liverpool United
Kingdom RuchikaBatraaolcombull Comment in bull J Cataract Refract Surg 2010 Apr36(4)701 author reply 701-2 bull Abstractbull An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphthguidelines for perioperative management of anticoagulated patients having cataract surgery Four hundred ninety-nine questionnaires were analyzed(56) The results showed that 295 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 warfarinwas being used to treat (as set by the treating physician) and considered sub-Tenon or topical anesthesia in anticoagulatedpatients
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
bull McMaster University Hamilton Ontario Canadabull Abstractbull 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 133123S-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 atrialfibrillation 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 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Chest 2008 Jun133(6 Suppl)299S-339SThe 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 Physicians531 Patients Who Are Receiving VKAs
bull 531 Patients Who Are Receiving VKAs
bull 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 (114 vs 048)[221] In these patients there were no major or clinically relevant nonmajor bleeds In another cohort study involving 639 patients who continued VKAs and 1203 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 (016 vs 008) and minor bleeding (141 vs 067) 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 (87)[224]
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Chest 2008 Jun133(6 Suppl)299S-339SThe 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
532 Patients Who Are Receiving Antiplatelet Drugs
bull 532 Patients Who Are Receiving Antiplatelet Drugs bull 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 3363 patients who continued aspirin (020 vs 065)[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 (006 vs 0) Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery [222] [223]
bull 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 perioperativemanagement will be driven by thromboembolic risk
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition) 2008
bull 53 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 45 and Section 46
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
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 )
bull 61 Patients Who Are Receiving VKAsbull 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 prothrombinconcentrates 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 25 to 50 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 25 to 50 mg without the need for blood product or recombinant factor VII administration [230] [232]
bull Recommendationbull 61 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 (25 to 50 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)
bull 62 Patients Who Are Receiving Antiplatelet Drugsbull 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 125 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 perioperativesetting 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
bull 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
bull Recommendationbull 62 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)
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant
medications complications
clopidogrel warfarin control
needle haematoma 8 62 43
subjunctivalhaemorrhage 44 32 17
any opcomplication 73 44
postcapsular rupture 32 17
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
The Cataract National Dataset electronic multicentre audit of 55567 operations antiplatelet and anticoagulant medications
complications
0
1
2
3
4
5
6
7
8
needle haematoma subjunctivalhaemorrhage
anyopcomplication
postcapsularrupture
clopidogrel
warfarin
control
aspirin only
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient2007
bull (1) Warfarin is effective at reducing health and life-threatening thrombotic events
bull (2) To stop warfarin risks stroke and death The risk for stroke increases to 1100
bull (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)
bull (4) If needle local anesthesia is performedthe risk for orbital hemorrhage is increased by 02 to 10
bull (5) Consideration should be given to using sub-Tenon or topical anesthesia
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Unstable coronary artery disease (CAD) or uncontrolledhypertension
bull 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 (eg 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
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
COPD
bull bull 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 cauteryis to be used
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Tamsulosin HCl alfuzosin HCl and other alpha1-adrenergic blocking agents may lead to IFIS92
bull bull 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bull ldquoCainerdquo allergies
bull Local anesthetics are either esters of benzoic and aminobenzoic derivatives (eg cocainebenzocaine procaine tetracaine butacaine) or amidederivatives of xylidine and toluidine groups (eg lidocaine mepivicaine prilocaine)
bull Skin testing for amide and ester local anesthetics can include preservative-freelidocaine which may identify patients allergic to the preservatives in amide anesthetics( Methylparaben)
bull
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Street clothes
bull 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 ldquofor 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 (egcataract surgery) However patients should still have their hair covered and be covered with clean linensrdquo
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Patient allergic to Xr contrast media
bull ldquoLittle 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 unfoundedrdquo82 In patients with povidone-iodine dermatitis an alternative skin preparationsolution 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Factors Lowering IOP
bull Drop in BP reduces choroidal volume
bull Relaxation of extraocular muscles lowers wall tension
bull Pupillary constriction facilitates aqueousoutflow
bull Mild hypocapnia (26 ndash 30 mmHg) reduceschoroidal blood volume
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Anaesthetic Requirement
bull Safetybull Akinesiabull Analgesiabull Minimal bleedingbull Avoidance or obtundation of oculocardiac reflexbull Prevention of rise in IOPbull Awareness of drug interactionbull Smooth emergence (no vomiting coughing retching)bull Pupil should be dilated for IO surgery (exceptbull glaucoma)bull Anaesthesia for Eye Surgery
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bull Can J Anaesth 2010 Jun57(6)602-17bull Anesthetic management for pediatric strabismus surgery Continuing professional developmentbull Rodgers A Cox RGbull Department of Anesthesia University of Calgary AB Canada aerodgershotmailcom ltaerodgershotmailcomgtbull Abstractbull 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
bull 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 peribulbarblocks and subtenon blocks Topical tetracaine drops have demonstrated mixed results and topical nonsteroidalanti-inflammatory drops were found not to be effective The use of opioids should be minimized due to the increased incidence of PONV
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Sedation requirements bull Sedation requirements (midaz 05 + fent 25 microgr pca)were similar for cataract
surgery under topical and retrobulbar anesthesia Eur J Ophthalmol 2004 Nov-Dec14(6)473-7 Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar blockBalkan BK Iyilikccedili L Guumlnenccedil F Uzuumlmluuml H Kara HC Celik L Durak I Goumlkel E
bull 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) 333ndash335 Patient preferences for anaesthesia management during cataract surgery D S FriedmanS W ReevesE B BassL H LubomskiL A Fleisher O D Schein
bull Midaz 0015 mgkg (003-004 recommended dosehellip)did not influence anxiety levels(Stai) and pain under topical anesth J Cataract Refract Surg 2004 Feb30(2)437-43 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiaHabib NE Mandour NM Balmer HG
bull Maintaining communication with the patientvoiceelectronic deviceshellip Eye 2004 Feb18(2)147-51 Patient communication during cataract surgeryMokashi A Leatherbarrow B Kincey J Slater R Hillier V
Mayer S
bull the addition of ketamine (132 +- 33 mg) to propofol (44 +- 11 mg) decreased the hypnotic requirement and improved the quality of sedation without prolonging recoveryAnesth Analg 1999 Aug89(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
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
Sedation requirements 2
bull dexmedetomidinegt saline Eur J Ophthalmol 2008 May-Jun18(3)361-7 Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedationErdurmus M Aydin B Usta B Yagci R Gozdemir M Totan Y
bull Alfentanil titrated + methoexital5168 ptsno problemshellipRand Eye Institute Pompano Beach Florida 33064 USAhellipOphthalmology 2000 May107(5)889-95Rand-Stein analgesia protocol for cataract surgeryRand WJ Stein SC Velazquez GE
bull bull The effect of combined topical-intracameral anaesthesia on
neuroleptic requirements during cataract surgery Can J Ophthalmol
2010 Feb45(1)52-7 Ho AL Zakrzewski PA Braga-Mele Rndash the addition of intracameral lidocaine to topical anaesthesia during
cataract surgery leads to a decrease in the administration of intraoperativefentanylnot midazolam
bull Eccecc
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bull Ophthalmology 2000 May107(5)889-95bull Rand-Stein analgesia protocol for cataract surgerybull Rand WJ Stein SC Velazquez GEbull Rand Eye Institute Pompano Beach Florida 33064 USAbull Abstractbull 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 intracameralanesthesia 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 patients 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bull J Cataract Refract Surg 2004 Feb30(2)437-43bull Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesiabull Habib NE Mandour NM Balmer HGbull Royal Eye Infirmary Plymouth England nabilhabibphntswestnhsukbull Abstractbull 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 (0015 mgkg 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 (Plt05) Patients were less anxious after administration of midazolam but this did not achieve statistical significance The mean pain score was 029 (range 0 to 4) in the sedation group and 038 (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 384 (range 0 to 4) and 388 (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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
bull Anaesthesist 1992 Nov41(11)673-9bull [Premedication in retrobulbar anesthesia A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]bull [Article in German]bull Heinze J Rohrbach Mbull Klinik fuumlr Anaumlsthesiologie Universitaumlt Tuumlbingenbull Abstractbull 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 iv 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) iv midazolam titrated until they became drowsy (17 patients 285 +- 084 mg [mean +-SD]) (2) sublingual flunitrazepam (16 patients 0005 mgkg) 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 iv 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 lmin during the operation by nasal cannula Differences between the three groups were analysed by Students t-test or U-test and a P value lt 005 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 lt 001) and flunitrazepam (P lt 005) 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 lt 005) 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 lt 005) in the midazolam group 10 min after acetazolamidecompared with the controls CONCLUSIONS The results of the study show the potential hazards of iv 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 hypnogeniceffects 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
