Ophthalmic Anesthesia in the Contemporary ASC

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Ophthalmic Anesthesia in the Contemporary ASC

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

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Ask Why

• No one right way to do any of this
• Systems are multifactorial and one piece of a
  system that works extremely well does not
  necessarily fit into another system
• Is it marketing or is it medicine, even if you
  are trying to marry them together dont forget
  which is which

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Managing Expectations

• Dont Overpromise!!!!
• You wont feel a thing
• Youll be asleep
• It only takes five minutes
• Youll be 20/20, reading and distance, with no
  astigmatism and never wear glasses

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Outline

• Clinical
• Preoperative evaluation
• Anesthetic, Efficiencies
• Economic
• ASA RVG
• Graduating Resident Opportunities
• Political
• AANA, ASA
• Employee, Independent Contractor

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Preoperative Evaluation

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

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Routine PreOp Tests

• Roizen,M Preoperative Laboratory Testing
  necessary or overkill? Can J Anesth 2004 / 516 /
  ppR1-R6
• Laboratory tests are not good screening devices
  for disease
• Results are costly to pursue, add new risk for
  pt, increase medicolegal risk for MD, make ORs
  inefficient
• More tests ordered more likely to have abnormal
  result
• Specificity of 95, if 2 tests ordered for pt
  with no disease chance of both being normal is
  .95 x .95 .90
• For 20 tests the chance that all will be normal
  is only 36
• Asymptomatic pt lt40 yo routine CXR causes harm to
  3 patients and benefits only 0.8 patients per
  1000 CXRs

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PreOperative Instructions

• Take all your meds in the morning
• From anesthesia standpoint we do not hold ASA,
  clopidogrel (plavix), coumadin
• Presently do 25,000 cases per year 15,000 with
  a block and 10,000 topical. Incidence of
  significant peribulbar hemorrhage once or twice a
  year
• Risks of stopping anticoagulation
• Late Thrombosis of Drug-eluting Stents Presenting
  in the Perioperative Period Anesthesiology 2007
  1061057-9, de Souza, University of Virginia
• Current ACC/AHA recommendations are 1 year of
  dual antiplatelet therapy for DES

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Preoperative Instructions

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

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Preoperative Drops

• Neosynephrine 10 contains 100mg of phenylephrine
  per ml
• One gtt is approximately 1/15th of one ml or 6mg
  of phenylephrine
• In cardiac surgery I give 100 ucg IV (1/60th of
  one gtt of 10) for hypotension, septic patients
  on phenylephrine drips get 100ucg to 400 ucg per
  minute
• New York State Guidelines on the Topical Use of
  Phenylephrine in the Operating Room,
  Anesthesiology Volume 92 (3) March 2000 pp
  859-864, Groudine
• Hypertension and Pulmonary Edema Associated with
  Subconjunctival Phenylephrine in a 2 month old
  Child during Cataract Extraction, Anesthesiology
  Volume 88 (5) May 1998 p 1394-96, Greher
• Adverse systemic effects from pledgets of topical
  ocular phenylephrine 10, American Journal of
  Ophthalmology 2002 Oct134 (4) 624-5, Fraunfelder

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Normal LV and Mitral Function
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Severe Hypertension
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Aspects of Eye Anesthetic

• Anxiolysis
• Pain relief
• Immobility
• Patient, Globe, Lids
• Stable IOP
• Lid function
• Hemodynamic, respiratory, metabolic stability

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Anxiolysis

• Talking to the patient
• Treat the patient the way you want yourself or
  your family to be treated, dont over promise
• Warm blanket
• PO meds
• Alprazolam (Xanax)
• Sublingual meds
• Midazolam (Versed)
• IV meds
• Midazolam (Versed), Propofol (Diprivan)

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Pain Relief

• Topical local anesthetics
• Tetracaine, lidocaine
• Drops or viscous
• Intracameral local anesthetics
• Preservative free lidocaine
• IV drugs
• Ketamine
• Narcotics (fentanyl)
• Injected local anesthetics
• Retrobulbar (intraconal)
• Peribulbar
• Sub tenons

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Immobility

• Injected local anesthetics (globe)
• Retrobulbar (intraconal)
• Peribulbar
• Sub tenons
• Injected local anesthetics (lids)
• Peribulbar
• Nadbath
• OBrien
• Van Lindt
• General anesthesia (patient)
• Anesthesia machine, Malignant Hyperthermia cart

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Stable IOP

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

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Hemodynamic Stability

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

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Metabolic Stability

• Take your insulin and eat on the day of surgery
• Check your blood sugar and adjust your meds and
  food intake as needed
• Non-aggressive in this setting with short term
  hyperglycemia, not looking for it
• No evidence that short term hyperglycemia affects
  ocular wound complications?
• Management of Hyperglycemia in the Hospital
  Setting, NEJM 35518 Nov 2006,1903-11, Inzucchi

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Efficiencies Where you do the IV, Sedation,
/- Block

• Preop Area
• 1 or more chairs per OR
• Time to establish some rapport
• Can be 1 or more cases ahead
• Easily 4 cases per room per hour, up to 6
• Operating Room
• 1 chair per OR
• Less time to establish rapport, more rushed feel
  for patient
• Easily 2 cases per room per hour, up to 4

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Our Anesthetic

• Preferably in Preop Area
• In a comfortable Lumex chair
• We do not use any stretchers
• When in the OR on a chair that reclines to the OR
  bed

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Our Anesthetic

• Topical
• no pre med in waiting area unless outrageously
  anxious
• 22 g IV in preop and midazolam, ketamine,
  propofol
• Topical and intracameral local
• Walk to the OR walk out of the OR

• Block
• no pre med in waiting area unless outrageously
  anxious
• 22 g IV in preop and midazolam, ketamine,
  propofol
• Peribulbar block 3 5 cc for cataract
• Walk to the OR walk out of the OR

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Our Anesthetic

• Topical
• Surgeon preference
• Patient preference
• Aphakic refractive cases (ARTs)
• Generally straightforward cataracts
• Well dilated

• Block
• Surgeon preference
• Patient preference
• Complicated cases
• IOL exchanges
• Trabs
• Valves
• Retina

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Hypothesis, Vitrectomy Rates

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

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

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IV Access

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

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Equipment

• MAC and Blocks
• Pacing defibrillator for the OR
• AED for the office
• Ambu bag versus Ventilator by state requirements

• General Anesthesia
• Anesthesia machine
• Stage 1 recovery
• Malignant Hyperthermia cart and protocol
• Ventilator

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Economics of Eye Anesthesia

• ASA Relative Value Guide
• Medicare 4 starting units plus time, 1/3 unit per
  5 minutes, multiplied by local conversion factor,
  17 in NY/NJ
• Private insurers may allow 6 units starting time
  and pay a full unit for any part of 15 mins, i.e.
  16 mins is 2 units, HMO payments in NY/NJ 35 -
  50 per unit, generally asked to participate with
  everyone
• NYU Residents 2007
• Generally offered at least 300k

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Economics of Eye OR

• 1 room OR
• 3 cases per hour
• 6 hours a day, 4 days a week, 50 weeks
• 3600 cases per year
• 4 million top line
• _at_ 20 profit 800k profit

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Political Anesthesia Provider

• CRNA vs. MD
• Employee vs. Independent Contractor

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Political ASA vs. AANA

• American Society of Anesthesiologists
• American Association of Nurse Anesthetists
• Independent Practice States
• Iowa, Nebraska, Idaho, Minnesota, New Hampshire,
  New Mexico, Kansas, N. Dakota, Washington,
  Alaska, Oregon, Montana, S. Dakota, Wisconsin