sometimes you feel like a schmuck

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caligas

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4 hour davinci hysterectomy with CRNA. Patient wakes up with bad eye irritation. Crna gives tetracaine drops with relief that lasts 2 hours, than bad irritation. I look at her eye, seems normal, vision ok. Talk to optho buddy who is doing another case, he says order erythromycin drops and he will look at her later. 3 hours later, he sees patient and immediately plucks an eye-lash out of her eye: patient cured.

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4 hour davinci hysterectomy with CRNA. Patient wakes up with bad eye irritation. Crna gives tetracaine drops with relief that lasts 2 hours, than bad irritation. I look at her eye, seems normal, vision ok. Talk to optho buddy who is doing another case, he says order erythromycin drops and he will look at her later. 3 hours later, he sees patient and immediately plucks an eye-lash out of her eye: patient cured.
Tetracaine drops to treat eye pain after surgery are a terrible idea!
Some CRNAs think that the purpose of taping the eyes is to prevent the eye balls from falling out so they tape the eyes really tight to secure them in place, and in the process they push the lashes against the conjunctiva and cause eye injury.
 
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You guys wouldn't use a couple drops of tetracaine ophthalmic drops as temporary relief until Ophthalmologist can see them? What is strange about this?
 
You guys wouldn't use a couple drops of tetracaine ophthalmic drops as temporary relief until Ophthalmologist can see them? What is strange about this?

If you do a basic eye exam for foreign body, it is a waste to consult the ophthalmologist. But no, I don't use those drops, even antibiotics are questionable.


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If you do a basic eye exam for foreign body, it is a waste to consult the ophthalmologist. But no, I don't use those drops, even antibiotics are questionable.

I have used tetracaine a couple times in PACU. Brings relief to patient, so it was worth it.
 
Great topic. We've had a bunch of corneal abrasion or irritation with robotic hyst and robotic prostates despite lube n tape. Anyone find a solution?
 
Great topic. We've had a bunch of corneal abrasion or irritation with robotic hyst and robotic prostates despite lube n tape. Anyone find a solution?

That's kinda strange. What are you guys doing to shield the face? Even if the pt took a robot arm or instrument to the face I'm not sure how that would cause an abrasion through the tape??
 
Great topic. We've had a bunch of corneal abrasion or irritation with robotic hyst and robotic prostates despite lube n tape. Anyone find a solution?
Don't use the lubricant! these things tend to dry inside the eye and become an irritant!
And when taping the eyes only gently tape the upper lids, don't cover the whole eye with tape.
 
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You guys wouldn't use a couple drops of tetracaine ophthalmic drops as temporary relief until Ophthalmologist can see them? What is strange about this?
Anesthetic drops anesthetize the conjunctiva and could make the injury worse since the patient will not feel the need to blink and protect the eye.
 
While I would agree with you Plank, I'm not talking about flipping the patient a bottle of tetracaine and sending them on their way. I have used these drops to facilitate examination of the eye, bring instant comfort to the patient. Most often, these have been corneal abrasions and not just an eyelash. So ophtho follow-up I have requested. I had seen one CRNA cause an ulcer that required months of follow-up.
 
That's kinda strange. What are you guys doing to shield the face? Even if the pt took a robot arm or instrument to the face I'm not sure how that would cause an abrasion through the tape??

We use either a padded mayo attached to the OR table side rail or the foam insert of a dupaco proneview. I'm sure it's not from direct trauma by the robot arms. There is a higher incidence of corneal abrasion with steep tberg which we always use for pelvic robot cases. Maybe secondary to corneal and conjunctival edema.



Don't use the lubricant! these things tend to dry inside the eye and become an irritant!
And when taping the eyes only gently tape the upper lids, don't cover the whole eye with tape.


I personally don't lube. Some of my partners do. Seems to make no difference. I make sure the lids are closed and cover the whole eye. What's the argument against that?

We get 1-2 per month but sometimes we'll get 2 in one week.
 
The person who should feel like a schmuck is the gyn for taking 4 hours for a robot hysterectomy.
 
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I personally don't lube. Some of my partners do. Seems to make no difference. I make sure the lids are closed and cover the whole eye. What's the argument against that?
We get 1-2 per month but sometimes we'll get 2 in one week.
The silicon adhesive in medical tape is not designed to be applied to the conjunctiva, So when it mixes with the tears it will enter the eye and cause irritation. Also applying tape to the whole eye may produce unnecessary pressure on the globe that increase the likelihood of injury.
All you need to do is allow the eye lid to close to protect the eye and that can be done by simply putting tape on the upper lid.
 
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While I would agree with you Plank, I'm not talking about flipping the patient a bottle of tetracaine and sending them on their way. I have used these drops to facilitate examination of the eye, bring instant comfort to the patient. Most often, these have been corneal abrasions and not just an eyelash. So ophtho follow-up I have requested. I had seen one CRNA cause an ulcer that required months of follow-up.

Curious to know more about that. How it was caused, diagnosed etc.
 
Our ophthalmologists have a standing order set including antibiotic and local anesthetic eye drops for suspected corneal abrasions.
 
You guys wouldn't use a couple drops of tetracaine ophthalmic drops as temporary relief until Ophthalmologist can see them? What is strange about this?
I guess its not totally crazy. Surprised people use it that way.

I was taught that topical local for eyeballs was to facilitate exam and treatment, not symptom relief for a patient. Numbing a possibly injured eye and then leaving the patient to their own devices for a while risked additional injury.

Never seen it done. We used to have fluorescein and uv lights in our PACU. Not sure if we still do. But I've never seen anyone wait hours for an exam.
 
Our ophthalmologists have a standing order set including antibiotic and local anesthetic eye drops for suspected corneal abrasions.
Don't you want to know if it is actually a corneal abrasion before your apply an anesthetic?
most commonly it is just irritation because of improper taping.
Next time just try to wash the eye with lots of NS and see if that solves the problem
 
Don't you want to know if it is actually a corneal abrasion before your apply an anesthetic?
most commonly it is just irritation because of improper taping.
Next time just try to wash the eye with lots of NS and see if that solves the problem

The board certified ophthalmologists are the ones making that decision, not me. Also, the local is partly diagnostic for the corneal abrasion.
 
The board certified ophthalmologists are the ones making that decision, not me. Also, the local is partly diagnostic for the corneal abrasion.
Really??? how is local diagnostic for corneal abrasion???
These Ophthalmologists obviously don't want to be called for an emergency consult and that's why they gave you this "standing order" but you are a physician after all and you should be able to use your clinical judgement to do what's right for your patient.
 
Really??? how is local diagnostic for corneal abrasion???
These Ophthalmologists obviously don't want to be called for an emergency consult and that's why they gave you this "standing order" but you are a physician after all and you should be able to use your clinical judgement to do what's right for your patient.

what other acutely painful eye conditions are instantly relieved by topical local anesthetic? It's not my area of expertise.
 
Clinical Updates


Perioperative Corneal Abrasions: Etiology, Prevention, and Management

By Jonathan Anson, M.D., Instructor in Anesthesia, Penn State University College of Medicine

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Anatomy review
How corneal abrasions occur
Protection Strategies
Risk Factors
Confirming and treating corneal abrasion
Summary
References

Corneal abrasions are the most frequent ocular complications following general anesthesia, and are a painful burden to the recovering postoperative patient. The most recent (1992) ASA closed claim analysis showed that eye injury occurred in 3 percent of all claims in the database (1). Of these claims, 35 percent represented corneal abrasions with a 16 percent incidence of permanent eye injury (1).

Corneal abrasions can occur during general anesthesia, monitored anesthesia care, and regional anesthesia. Several strategies are widely used to try and prevent corneal abrasions, although there is a paucity of recent studies to support one method over another. This review will discuss common causes of peri-operative corneal abrasions and review the literature supporting various approaches to prevention. The basic management of this painful condition will also be discussed.

Anatomy review

In order to understand the causes of perioperative corneal abrasions some pertinent anatomy must first be reviewed. The cornea is an avascular structure composed of five histologically distinct layers. It is protected by a precorneal tear film composed of three layers: Lipid, aqueous, and mucin. The outermost lipid layer prevents evaporation of the aqueous layer and acts as a lubricant. The aqueous layer oxygenates the corneal epithelium, while the main function of the mucin layer is to create a hydrophilic surface on the corneal epithelium. The precorneal tear film is regenerated by blinking, thus the absence of blinking during general anesthesia renders the cornea vulnerable to injury.

The cornea is extremely sensitive to hypoxia and the partial pressure of oxygen in the cornea can decrease dramatically with as little as 30 seconds of hypoxia (2). Corneal hypoxia leads to edema and potential for loss of the epithelial layer, causing an abrasion. Therefore, physiologic factors that alter corneal blood flow can predispose patients to corneal injury. This includes conditions that decrease arterial blood flow such as elevated intra-ocular pressure, head malpositioning, or pressure from an incorrectly applied face mask. Decreased venous return can similarly lead to corneal edema and subsequent abrasion.

(2). Normally lid closure while sleeping is maintained by the orbicularis muscles, but under anesthesia up to 59 percent of patients fail to have complete eye closure (2). The risks of lagopthalmos are increased by the abolishment of both blinking and Bell’s phenomenon (normal upward turning of the eye while asleep) during general anesthesia.

General anesthesia reduces tear production which leads to corneal drying (3). One small study demonstrated a significant decrease in basal tear production under general anesthesia. After one hour basal tear production decreased from a baseline of 13.6 ml per five minutes to just 0.9 ml per five minutes (P < 0.001) (3). Corneal drying in the presence of lagophthalmos can lead to dry patches and corneal abrasion. The effect of anesthetic duration on tear production and risk of corneal abrasion was further demonstrated in a study utilizing fluorescein and a slit lamp to monitor the corneas of patients undergoing general anesthesia. The study concluded that corneal changes are evident after 100 minutes of anesthesia and eye erosions after two hours (2). Other studies have similarly demonstrated that these changes peak around two hours and are not seen in anesthetics with less than a one hour duration.

While the majority of corneal abrasions are caused by lagophthalmos and changes in tear production induced by general anesthesia, traumatic injuries occur as well. These injuries are often caused by face-masks, dangling name badges, laryngoscopes, or “stethoscope necklaces” during airway management. Chemical injuries can occur from surgical prep cleaning solutions or application of benzoin without adequate eye protection. Post-operative eye injuries are most often attributable to patients rubbing their eyes, pulse oximeters, and bed linens. Applying the pulse oximeter probe to the 5th digit rather than the index finger may alleviate some of the corneal injuries that occur post-operatively.

(2). Parrafin based products can cause erythema and edema during halothane anesthetics as halothane is highly soluble in paraffin and high concentrations can result in inflammation, but this is not seen with newer volatile anesthetics.

Cucchiara, et al (4) compared the effectiveness of eye ointment plus eye tape versus eye tape with no ointment. They looked at 4,652 neurosurgical patients, about half of which received ointment and eye tape while the rest had their eyes taped without ointment. Four patients in each group were found to have corneal abrasions post-operatively. Five of the eight patients were in the prone position. Thus, they were unable to show any protective effect of routine use of eye ointment in their neurosurgical patient population (4).

(5). These were found to be more common in patients undergoing surgery in the prone or lateral position. Head and neck surgery, sustained hypotension, and anemia were also found to be risk factors (5). The conclusions made by this group were supported in another retrospective study examining 60,965 at the University of Chicago. They similarly reported lateral position and head/neck procedures as risk factors for corneal injury. In addition, this study found that increased length of surgery was an independent risk factor (6).

(7). Indications for referral to a specialist include: history of significant trauma, worsening of symptoms despite treatment, erosion, infiltrate around the edges of the abrasion (suggestive of infection) (7). Corneal abrasions generally do not lead to long term complications, however, in rare instances the healed epithelium may be poorly adhered to underlying layers leading to recurrent corneal erosions.

Historically, eye patching has been utilized in the management of corneal abrasion. Recently, several studies have shown that patching is not helpful and may in fact delay healing (7, 8). Small abrasions often do not need treatment and patients should be reassured that they heal within 24-72 hours. Topical non-steroidal anti-inflammatory drugs such as diclofenac or keterolac can be considered as they have been shown to reduce pain. The use of antibiotics is more controversial. The incidence of infection following corneal abrasion is <1 percent, however, some clinicians use prophylactic antibiotics because a concomitant infection will slow healing. A prospective cohort study of prophylactic topical antibiotics (chloramphenicol) did demonstrate a decrease in ulcer formation when started within 18 hours of injury (9). Thus, antibiotic drops may be indicated to prevent ulcers. On the other hand, topical anesthetics should never be used as they can hinder healing, mask worsening symptoms, and lead to keratitis.

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NY Presbyterian hospital:

901901.fig.001.jpg

Figure 1: Corneal abrasion treatment algorithm.
 
Our ophthalmologists have a standing order set including antibiotic and local anesthetic eye drops for suspected corneal abrasions.
Most eye doctors will advise against local anesthetic drops in the eye. ANd I have asked many of them. It delays healing the abarasion.. Tape the eye shut for a period of time.
 
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Most eye doctors will advise against local anesthetic drops in the eye. ANd I have asked many of them. It delays healing the abarasion.. Tape the eye shut for a period of time.

ours say never tape it shut and they always want some local drops
 
Blade - thank you for the useful posts.
 
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