Boston Globe article about blindness from ocular anesthesia

[amLOLdipine]

That "other site" has already posted this to their front page as propaganda.



https://www.bostonglobe.com/metro/2...gery-errors/a0IqJVEjyWFmNdBSNoiOqK/story.html

The injuries have shocked and mystified cataract surgeons, who say even one serious injury is rare, and led specialists who examined the patients to conclude that the anesthesiologist on the cases, Dr. Tzay Chiu, possibly pierced their eyeballs or retinas with his needles, according to the surgery center’s investigative reports submitted to the state. Chiu’s attorney, Rebecca Capozzi in Waltham, declined to comment.

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[rakotomazoto]

I read the article. The irony is that this is a case of lack of oversight, new anesthesiologist working in a new environment, probably didn't even realized what he didn't know, just like our friends on the "other site". It's nice to know that there is always a pack of haters just waiting in the wings to swoop in and criticize every decision made in doing a difficult job well.

 

[PainDrain]

My question is why even do a retrobulbar block? Or better yet why not let the surgeon do it? It takes the risk out of your hands.

In my experience the only reason to do a retrobulbar block for a cataract is to pad the billing.

 

[jwk]

My question is why even do a retrobulbar block? Or better yet why not let the surgeon do it? It takes the risk out of your hands.

In my experience the only reason to do a retrobulbar block for a cataract is to pad the billing.

We haven't done any eye blocks in 20 years. Potential high risk and zero benefit. 99% of ours are done with topical + MAC. The 2-3 surgeons out of about 30 who refuse to see the light are required to do their own blocks.

 

[pgg]

I used to moonlight at an ASC where an ophthalmologist would churn through the eyeball cases. He'd do retrobulbar blocks for all of them. Block patient in preop, do another case, then block the next and take the previously blocked patient to the OR. It was a machine.

He kept trying to talk me into doing his blocks. He was really obnoxious about it, openly questioning why I was afraid to do a retrobulbar when I'd stick needles in spines and necks.

He actually had a really nice technique using a short needle just under the globe that I believe was probably safer than the usual deep stick method. Somehow he talked the anesthesia group here to give induction dose size hits of propofol in preop so he could do the blocks, which was a whole 'nother issue. But I never did a retrobulbar block, and surely never will.

The patients looked great postop and were discharged minutes after leaving the OR. Very efficient. High patient satisfaction. I can see why he did them that way. I'm sure he's done 10 or 20,000 of them, at least.

 

[Planktonmd]

They should also look at the anesthetic solution that was used and verify the actual vials if possible.
Who knows, it might be a manufacturer's error!

 

[Planktonmd]

I used to moonlight at an ASC where an ophthalmologist would churn through the eyeball cases. He'd do retrobulbar blocks for all of them. Block patient in preop, do another case, then block the next and take the previously blocked patient to the OR. It was a machine.

He kept trying to talk me into doing his blocks. He was really obnoxious about it, openly questioning why I was afraid to do a retrobulbar when I'd stick needles in spines and necks.

He actually had a really nice technique using a short needle just under the globe that I believe was probably safer than the usual deep stick method. Somehow he talked the anesthesia group here to give induction dose size hits of propofol in preop so he could do the blocks, which was a whole 'nother issue. But I never did a retrobulbar block, and surely never will.

The patients looked great postop and were discharged minutes after leaving the OR. Very efficient. High patient satisfaction. I can see why he did them that way. I'm sure he's done 10 or 20,000 of them, at least.

What you are describing (short needle under the globe) is not a retrobulbar block, it is a peri-bulbar block and it is definitely safer because you don't attempt to go behind the globe.
It's unfortunate that new guys finish residency and never learn how to do a peribulbar block these days!

 

[pgg]

No, it was retrobulbar. Peribulbars would be expected to miss CN II and he absolutely got it, every time. He's he only one I've ever seen do them that way. He'd use a 3/4" (? I think?) needle and drop it under the globe, hub it, angle it behind the globe, let it wiggle freely to prove to himself it wasn't engaged in the globe or another structure, and then inject something like 4-8 mL. Single injection.

They were blind by the time the room air general anesthetic they got for the block wore off.

 

[deepstate2016]

Like any other procedure it can be done safely by a trained experienced confident clinician. I know a CRNA that performed literally thousands of these blocks over 20 years with no complications. Confidence is knowing what you know and not being buffaloed into doing something you do not know.
And who knows could be contaminated drugs.

 

[Planktonmd]

No, it was retrobulbar. Peribulbars would be expected to miss CN II and he absolutely got it, every time. He's he only one I've ever seen do them that way. He'd use a 3/4" (? I think?) needle and drop it under the globe, hub it, angle it behind the globe, let it wiggle freely to prove to himself it wasn't engaged in the globe or another structure, and then inject something like 4-8 mL. Single injection.

They were blind by the time the room air general anesthetic they got for the block wore off.

Interesting...

 

[fakin' the funk]

My question is why even do a retrobulbar block? Or better yet why not let the surgeon do it?

Um, this!

About half our ophthos do 100% topical, maybe 25% all blocks and the remaining 25% blocks/topical selectively.

There's no way I would do an ocular block for an ophthalmologist. a) unnecessary b) high risk c) that's THEIR FREAKING ORGAN

 

[Mman]

vast majority of our cataracts are done under topical anesthesia with no sedation other than oral benzo by the ophthalmologist. The rest we provide some moderate sedation for while they place the retrobulbar block. And moderate sedation is usually not much at all. Maybe 30-50 mg of propofol while the RN holds the patient's head still. They are still breathing.

 

[urge]

Um, this!

About half our ophthos do 100% topical, maybe 25% all blocks and the remaining 25% blocks/topical selectively.

There's no way I would do an ocular block for an ophthalmologist. a) unnecessary b) high risk c) that's THEIR FREAKING ORGAN

I did a lot of eyeballs as a ca1. The ophtos never taught me how to do a block thus I will never do a block for them.

 

[BLADEMDA]

Like any other procedure it can be done safely by a trained experienced confident clinician. I know a CRNA that performed literally thousands of these blocks over 20 years with no complications. Confidence is knowing what you know and not being buffaloed into doing something you do not know.
And who knows could be contaminated drugs.

All it takes is ONE complication to realize that nothing we do, and I mean nothing, is without risk. The question is why should an Anesthesiologist take on this added risk? FYI, there is NO payment for the block as it is part of the anesthetic or surgical fees.

 

[PainDrain]

All it takes is ONE complication to realize that nothing we do, and I mean nothing, is without risk. The question is why should an Anesthesiologist take on this added risk? FYI, there is NO payment for the block as it is part of the anesthetic or surgical fees.

I always thought you could bill the block because it is for "post-op pain control". That is why some shady places do them, to pad the bill.

 

[Pooh & Annie]

I always thought you could bill the block because it is for "post-op pain control". That is why some shady places do them, to pad the bill.

If a payer can argue the procedure could be done with the block, then they will and that's your anesthetic.

There was a move by this state's CMS a couple years ago to not reimburse epidurals placed pre-op. The patient had to have documented severe post-op pain requiring something beyond systemic analgesia. It almost went through, based 100% on recommendations made by people who know NOTHING about surgical patients.

 

[KurtBrie]

Just so everyone is aware, in a cat/iol case the block cannot be billed extra by the surgeon or you, its bundled and cannot be unbundled. So its basically a MAC case and on average a medicare CAT/IOL is paying about 100$ (i think a little less).

I have done a number of RB blocks but I have not done them in years. The guys who want them can do them, not me.

The fellow in this article sounds like he is a cowboy without an understanding of his limitations. The most dangerous type.

Sad stuff for the patients.

 

[deepstate2016]

All it takes is ONE complication to realize that nothing we do, and I mean nothing, is without risk. The question is why should an Anesthesiologist take on this added risk? FYI, there is NO payment for the block as it is part of the anesthetic or surgical fees.

I do not recall saying no risk. Hell intubation carries risks. The point I was making was true confidence is shown by calling for help if you are unsure, an experience matters.

 

[Planktonmd]

One thing to learn from this disaster: if you don't know how to do something DO NOT DO IT!