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COPD for cataract

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NJPAIN

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I'm an anesthesiologist but I've been in pain practice for many years. Spent years in academics doing anesthesia and pain but now just pain for long enough that a lot of things like eyes I have little recollection of. I have a famil member (mom) age 89, morbid obesity and moderate to severe copd with bronchiectasis. On supplemental oxygen at 2-3 liters/min, bronchodilators and inhaled steroids. Vision deteriorating due to cataracts. I have putting it off and putting it off but now she can barely read and that is one of her few remaing pleasures. My question is to those of you who regularly do eyes. I understand that this is a "peripheral" surgery that can be done with topical anesthesia or regional. However, from a practical standpoint can this be done in someone with these comorbities that prevent someone from lying flat and may experiencing coughing during the procedure? I recall eye patients having multiple medical problems but I don't recall these severe pulmonary issues and do recall coughing is a no-no. Appreciate any input
 

psychbender

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We do eyes at my hospital only about once a week, and get at least one person like you describe each day we do eyes. In general, if the patient cannot lie flat, or there is concern of coughing a lot during the procedure, we do the procedure under general anesthesia. If we do not think that the patient can get through GA, then they are cancelled. Otherwise, so long as they can tolerate lying flat and not coughing, they get some PO valium on check-in, local anesthesia drops, and that's it. The CRNA just sits there and charts vitals.
 
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deleted171991

I'm an anesthesiologist but I've been in pain practice for many years. Spent years in academics doing anesthesia and pain but now just pain for long enough that a lot of things like eyes I have little recollection of. I have a famil member (mom) age 89, morbid obesity and moderate to severe copd with bronchiectasis. On supplemental oxygen at 2-3 liters/min, bronchodilators and inhaled steroids. Vision deteriorating due to cataracts. I have putting it off and putting it off but now she can barely read and that is one of her few remaing pleasures. My question is to those of you who regularly do eyes. I understand that this is a "peripheral" surgery that can be done with topical anesthesia or regional. However, from a practical standpoint can this be done in someone with these comorbities that prevent someone from lying flat and may experiencing coughing during the procedure? I recall eye patients having multiple medical problems but I don't recall these severe pulmonary issues and do recall coughing is a no-no. Appreciate any input
You need 2 things:
1. A fast private surgeon. Pre-incision time of 5-10 minutes, surgical time under 10 minutes usually, topical anesthesia, able to work even standing, with the head of the bed elevated, if needed. Yes, they exist. (Your anesthesiologist colleagues will give you names.)
2. A good, kind, reassuring, literally hand-holding (if needed) anesthesiologist, who does a lot of these procedures with that surgeon. MAC is an art.

With very few exceptions (that usually have to do with mental/psych status and bad tremor), one doesn't need GA for cataracts, unless the surgeon (+/- the anesthesiologist) is incompetent/lazy. Cough can be fixed with small doses of opiates (unless it's really bad), and anxiety with the right dose of sedatives and reassurance. 99% of the patients will do just fine under topical if the surgeon can do her job under 10 minutes, even with just "it's OK" anesthesia. These patients are usually very motivated, and will do well with the right surgeon and the right anesthesiologist.
 
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nap$ter

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You need 2 things:
1. A fast private surgeon. Pre-incision time of 5-10 minutes, surgical time under 10 minutes usually, topical anesthesia, able to work even standing, with the head of the bed elevated, if needed. Yes, they exist. (Your anesthesiologist colleagues will give you names.)
2. A good, kind, reassuring, literally hand-holding (if needed) anesthesiologist, who does a lot of these procedures with that surgeon. MAC is an art.

With very few exceptions (that usually have to do with mental/psych status and bad tremor), one doesn't need GA for cataracts, unless the surgeon (+/- the anesthesiologist) is incompetent/lazy. Cough can be fixed with small doses of opiates (unless it's really bad), and anxiety with the right dose of sedatives and reassurance. 99% of the patients will do just fine under topical if the surgeon can do her job under 10 minutes, even with just "it's OK" anesthesia. These patients are usually very motivated, and will do well with the right surgeon and the right anesthesiologist.

this is a great post.

out of residency my first gig was at a VA - every single cataract pt was an ASA 4 cardiopulmonary cripple.

my first day supervising the cataract room i worked with this little old crna - when i told her of my plan for GA with etomidate induction and partial ketamine maintenance for our first morbidly obese motorized cart-bound CAD/CHF/COPD/polysubstance abuse pt on 24/7 O2 (who could not lie flat) - she smiled patiently, and said "is it ok if we try a little of the usual first?" (varying amounts of versed/fentanyl/propofol).

trying to establish rapport with staff and realizing we would be unlikely to burn clinical bridges with just a whiff of the "usual", i agreed. despite my doubts it worked all day.

as FFP stated - great fast surgeon good with local willing to get into slightly awkward positions for quick cataract surgery with anesthesia provider great at setting expectations and hand-stroking = success all day long with minimal risk.
 

Ignatius J

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You need 2 things:
1. A fast private surgeon. Pre-incision time of 5-10 minutes, surgical time under 10 minutes usually, topical anesthesia, able to work even standing, with the head of the bed elevated, if needed. Yes, they exist. (Your anesthesiologist colleagues will give you names.)
2. A good, kind, reassuring, literally hand-holding (if needed) anesthesiologist, who does a lot of these procedures with that surgeon. MAC is an art.

With very few exceptions (that usually have to do with mental/psych status and bad tremor), one doesn't need GA for cataracts, unless the surgeon (+/- the anesthesiologist) is incompetent/lazy. Cough can be fixed with small doses of opiates (unless it's really bad), and anxiety with the right dose of sedatives and reassurance. 99% of the patients will do just fine under topical if the surgeon can do her job under 10 minutes, even with just "it's OK" anesthesia. These patients are usually very motivated, and will do well with the right surgeon and the right anesthesiologist.

Sounds like a bread and butter phaco. Shouldn't be a problem.
 

Wiscoblue

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Cataract is like getting a haircut. If done quickly (usual time 10 minutes) using topical with no sedation, your mom could be in and out of the hospital in a couple of hours. Good luck.


Sent from my iPad using Tapatalk
 

jwk

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For an almost office procedure that takes 6 minutes, and is completely comfortable under topical drops? Hope you are kidding.
We have a couple surgeons left out of the 30 or so eye docs we work with that still want a block for a routine cataract. They can't wrap their heads around topical, even though that has been the norm for most for nearly 20 years. Although perfectly competent otherwise, I would never send a friend or family member to one of these surgeons. We used to do PBB for these as a courtesy, and stopped doing that about 15 years ago - too much potential risk for zero benefit. Eye doc wants a block? Fine. We'll sedate the patient and let them take the myriad risks of PBB/RBB.

I'll have to say that I've never seen a cataract procedure done in anything but the supine position, and we do a boatload of them.
 

norwood

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Only thing I'd add to all this is that some surgeons are OK with a pt interrupting them once or twice to cough. Pt gives advance warning, surgeon pulls the instruments out of the eye, pt coughs, surgeon goes back to work. I've seen eye guys who will gladly go along with any request that isn't either unsafe or massively inconvenient, and I've also seen eye guys who want everything one particular way. Talk to the surgeon, get a feel for how s/he works.
 

GhostTree

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prop, sux, tube...

oh wait....

forgot the retrograde wire.


Seriously though, she should be fine.

If the coughing is so bad that she can't lay still, maybe try some nebulized lidocaine. But what she really needs is a quick surgeon.
 

Eyefixer

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Interesting read. I am practicing cataract surgeon and I thought I'd share my perspective. Currently, I do about 40 cases/months rapidly closing in on ~6000 cataracts at this point, so I have a little experience. In addition, a few years ago I worked for a group where ophthalmologists were forced to do what they called "procedural sedation" meaning I pushed my own versed and fentanyl with anesthesiologist being "available" somewhere within the surgery center (yikes). I've done ~1800 cataracts that way. In my current group, we have a great anesthesia group that doesn't employ CRNAs.

OP, I don't know the details of your mom's ophthalmic history, but please don't count on this being a "15 minute cataract" or it being "like getting a haircut". Sounds like there will be positioning issues. With COPD and morbid obesity, I guarantee there will be significant posterior vitreous pressure that the surgeon will be fighting against the whole case. In addition, its an 89 year old lens which is likely dense (some cataracts are like cheese and some are like rocks). Remember, cataract surgery either goes very well (99% of the time for a good surgeon) or horribly (sometimes irreversibly) wrong.

My recommendation- discuss pre-op game plan with the surgeon you choose. Oftentimes, with back or breathing issues its just better to put the patient to sleep and finish the case in 15 min rather than struggle with straining uncomfortable patient and potentially encounter a complication that will take another hour to fix. PM me if you have any specific questions. GL
 
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Planktonmd

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Interesting read. I am practicing cataract surgeon and I thought I'd share my perspective. Currently, I do about 40 cases/months rapidly closing in on ~6000 cataracts at this point, so I have a little experience. In addition, a few years ago I worked for a group where ophthalmologists were forced to do what they called "procedural sedation" meaning I pushed my own versed and fentanyl with anesthesiologist being "available" somewhere within the surgery center (yikes). I've done ~1800 cataracts that way. In my current group, we have a great anesthesia group that doesn't employ CRNAs.

OP, I don't know the details of your mom's ophthalmic history, but please don't count on this being a "15 minute cataract" or it being "like getting a haircut". Sounds like there will be positioning issues. With COPD and morbid obesity, I guarantee there will be significant posterior vitreous pressure that the surgeon will be fighting against the whole case. In addition, its an 89 year old lens which is likely dense (some cataracts are like cheese and some are like rocks). Remember, cataract surgery either goes very well (99% of the time for a good surgeon) or horribly (sometimes irreversibly) wrong.

My recommendation- discuss pre-op game plan with the surgeon you choose. Oftentimes, with back or breathing issues its just better to put the patient to sleep and finish the case in 15 min rather than struggle with straining uncomfortable patient and potentially encounter a complication that will take another hour to fix. PM me if you have any specific questions. GL
No one is trying to underestimate the potential complexity of a complicated cataract surgery but if this 89 Y/O advanced COPD and morbidly obese is going to need GA for her cataract surgery I would argue that the risk of this anesthetic outweighs the benefit.
In other words it's probably better for her to keep her cataract than to end up intubated on a ventilator in the ICU and what might follow that.
 
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deleted59964

interesting blocks are uncommon in the states - here they are routine - PBB or sub-tenon.
some of our surgeons want complete akinesis, others don't care - but they pretty much all get a block or GA.

jwk - not so sure about a "myriad of complications" - they're generally very safe blocks.
 
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deleted59964

For an almost office procedure that takes 6 minutes, and is completely comfortable under topical drops? Hope you are kidding.
nope

maybe our slick private practice surgeons do them in 6 minutes -- mostly in the centres I've worked at they take 15-20 min
 

Eyefixer

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interesting blocks are uncommon in the states - here they are routine - PBB or sub-tenon.
some of our surgeons want complete akinesis, others don't care - but they pretty much all get a block or GA.

jwk - not so sure about a "myriad of complications" - they're generally very safe blocks.


Blocks are just as common in the US as anywhere else. We try to move away from block as cataract surgery is rapidly moving from vision restoration to refractive procedure (i.e. customer "experience" and "satisfaction" are very important).

In this case, retrobulbar block would not solve positioning or breathing issues.
 
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