Ischemic Optic Neuropathy with spines

[sigrhoillusion]

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Anyone ever have this unfortunate complication occur?

Just wondering what everyone's approach was when discussing anesthesia for their posterior spine surgeries. Do you make any emphasis to talk about it during the anesthesia consent? Do you briefly mention it in passing? Do you specifically write it down on the form/or electronically? If you do talk about it, how in depth do you go? If you do go in depth, do you also at that point go into more serious complications (i.e. cardiac arrest) that may also occur from any anesthetic? Have any patients gotten the info and been like "NO THANKS!"? And do your surgeons mention in their consent/explanation of outcomes from the surgery?

Sorry for the million questions, just trying to get a feel of what everyone else's practices are.

 

[okayplayer]

I don't mention it. If it happens to you you will get sued whether you mention it or not.

 

[deleted171991]

I don't mention it. If it happens to you you will get sued whether you mention it or not.

Big mistake. If you don't mention it, they can get you for the consent not having been an informed one, versus getting away with them not being able to find any fault in your anesthetic management. It's a major well-known complication, even if rare. You will come across as a greedy used car salesman who just wanted to close the deal on a wreck. You could be hit with punitive damages or worse.

 

[Planktonmd]

Big mistake. If you don't mention it, they can get you for the consent not having been an informed one, versus getting away with them not being able to find any fault in your anesthetic management. It's a major well-known complication, even if rare. You will come across as a greedy used car salesman who just wanted to close the deal on a wreck. You could be hit with punitive damages or worse.

I wish consents were as valuable as you think 🙂

 

[Noyac]

It's on my consent.

 

[deleted171991]

I wish consents were as valuable as you think 🙂

They are not. But lack of them is.

 

[risnwb]

It's on my consent.

Do you have a specific consent for prone spine cases? Or do you write it in. And do you discuss it with patient?

I think this is something surgeons should be discussing before the day of surgery because it's a little more difficult for a patient to back out because of a rare complication when sitting in pre-op with a Hospital gown and an iv in place.


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[polar403]

Do you have a specific consent for prone spine cases? Or do you write it in. And do you discuss it with patient?

I think this is something surgeons should be discussing before the day of surgery because it's a little more difficult for a patient to back out because of a rare complication when sitting in pre-op with a Hospital gown and an iv in place.


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You can write in possibility of vision loss. Just tell the patient the risk is higher due to positioning for the surgery but that it is rare and you do all that you can with checking the eyes frequently throughout the case (document!) and monitor the blood pressure to decrease the risk. That seems to alleviate most concerns.

 

[dhb]

checking the eyes frequently throughout the case (document!)

How does that do any good?

 

[ranvier]

The ansthesia safety foundation has good info on this and emphasizes that the surgeon should mention it prior to day of surgery.

 

[polar403]

How does that do any good?

Despite not being in the summary recommendations of the ASA Task Force on perioperative blindness, Miller recommends frequent eye checks during surgery (no current recommendations on how frequently, however every 15-30 minutes isn't entirely unreasonable). Miller states it may help prevent central retinal artery occlusion.

I understand that if the patient hasn't moved at all since you last checked them that the likelihood of any change is slim, but there is always a chance the position shifted when you weren't looking or something happened while you got a break. Rare, but possible. We are in the business of safety.

 

[Arantius]

I mentioned this during a consent the other day on a patient who was having an elective spine surgery and even the remote possibility of vision loss caused her to cancel the surgery. She had no idea, and no surgeon had mentioned it.

 

[sigrhoillusion]

I mentioned this during a consent the other day on a patient who was having an elective spine surgery and even the remote possibility of vision loss caused her to cancel the surgery. She had no idea, and no surgeon had mentioned it.

See it's stories like this that make me wonder what the surgeons are telling patients. If I was not informed of a complication like this, which has been linked to prone spine cases, I'd probably be upset as well if I was a patient. Obviously, I being a doctor know these risks, but the patients usually only focus on the benefits. I'm sure the surgeon mentions the risk of paralysis, and otehr risks related to the procedure. Even an educated patient, might not think blindness would be a risk for this type of case.

 

[BLADEMDA]

I don't mention it. If it happens to you you will get sued whether you mention it or not.

Yes, you will get sued but the difference can be $200K if you mentioned it as noted in the consent vs $1 million if you didn't bother.

I have seen this complication after a patient had 12 hours of lumbar spine surgery in the prone position.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017302/

 

[BLADEMDA]

 

[BLADEMDA]

All 23 cases involved an anesthetic time of more than 5.5 hours and a median estimated blood loss of 2.2 liters (range 100ml to >12 liters). Significant hypotension (defined as systolic blood pressure or mean arterial pressure Ž 40 percent below baseline) was present in 52 percent of cases.


https://depts.washington.edu/asaccp/sites/default/files/pdf/Click here for _63.pdf


http://www.ucdenver.edu/academics/c...ents/08 Janik POST-OPERATIVE VISUAL LOSSP.pdf

 

[Hoya11]

All 23 cases involved an anesthetic time of more than 5.5 hours and a median estimated blood loss of 2.2 liters (range 100ml to >12 liters). Significant hypotension (defined as systolic blood pressure or mean arterial pressure Ž 40 percent below baseline) was present in 52 percent of cases.


https://depts.washington.edu/asaccp/sites/default/files/pdf/Click here for _63.pdf


http://www.ucdenver.edu/academics/colleges/medicalschool/departments/Anesthesiology/crash/crasharchives/Documents/08 Janik POST-OPERATIVE VISUAL LOSSP.pdf

I have never seen it but am aware that it does occur. I wonder what is the actual incidence? Is it more common than things like MI/PE/Stroke/Death? Do you tell everyone in the consent for every surgery that there is a risk of stroke/death? I dont.. but the paper they sign does say it. I have a hunch this is one of those things we make a big deal about but is soo rare and probably not more common than stroke/death/Pe/MI

 

[BLADEMDA]

I have never seen it but am aware that it does occur. I wonder what is the actual incidence? Is it more common than things like MI/PE/Stroke/Death? Do you tell everyone in the consent for every surgery that there is a risk of stroke/death? I dont.. but the paper they sign does say it. I have a hunch this is one of those things we make a big deal about but is soo rare and probably not more common than stroke/death/Pe/MI

A recent review by Shen and colleagues of 5.6 million patients from the National Inpatient Sample (NIS) found that the incidence of POVL to be 3.09/10000 (0.03%) after spinal fusion and 8.64/10000 (0.09%) after cardiac surgery[5]. Other large-scale series suggest that the rate of POVL may be even higher after spine surgery, with incidence rates ranging from 0.094%[4] to 0.2%[8].

 

[BLADEMDA]

I have never seen it but am aware that it does occur. I wonder what is the actual incidence? Is it more common than things like MI/PE/Stroke/Death? Do you tell everyone in the consent for every surgery that there is a risk of stroke/death? I dont.. but the paper they sign does say it. I have a hunch this is one of those things we make a big deal about but is soo rare and probably not more common than stroke/death/Pe/MI

I agree it's rare with an incidence of around 0.1%. That said, the complication is devastating and seems to be much harder for a patient or family member to accept than MI, CVA, etc.
Whether you decide to discuss this rare but devastating complication with patients is your decision. But, the "experts" seem to believe that you should include it for certain subgroups undergoing spine surgery.

 

[BLADEMDA]

In practice, a complication that is likely to occur more than 1% of the time is often mentioned, but certain less frequent complications may be so grave that the doctor feels it wise to mention them. For example, permanent loss of vision following routine cataract surgery occurs in approximately 4 in 1000 cases and should be routinely mentioned. Some complications are so extremely rare that they need not be routinely mentioned; however, if asked a direct question concerning the possible occurrence of such a complication, the doctor must answer truthfully.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1791005/

 

[leaverus]

I agree it's rare with an incidence of around 0.1%. That said, the complication is devastating and seems to be much harder for a patient or family member to accept than MI, CVA, etc.
Whether you decide to discuss this rare but devastating complication with patients is your decision. But, the "experts" seem to believe that you should include it for certain subgroups undergoing spine surgery.

Yeah but why us? I realize it's a multi factorial complication, but I would argue its more a surgical one than an anesthetic one. I think there should be more emphasis on the surgeon telling the pt in the office long before surgery than me who's just met an extremely nervous pt on the day of a big surgery.

 

[Pharmado]

It does seem like an issue the surgeon should address first, but since we will likely deal with the fallout from the complication, it lands in our laps to discuss it with the patient. I haven't routinely discussed this with my patients, although I have mentioned it prior to large surgeries. I have a pair of large spine cases tomorrow and after reading through this discussion I now plan to discuss the possibility with my patients and hopefully in the future I will do it consistently. I wish that informed consent truly acted as a barrier for litigation especially when we've truly done our part to prevent complications, but it seems we can pretty much be sued at the whim and will of the patient if anything goes wrong.

 

[chocomorsel]

Used to do tons of spine. In fact that was my primary practice. Used to have scoliosis fusions that would lose 2 liters or more and would be fighting hypotension frequently enough. Never had that complication. Never mentioned it to my patients. I highly doubt the surgeons did either. They tend to gloss over risk and focus on the benefits and we all know what the research has say about that. Patients are clueless.

Glad I don't do that very much anymore.

 

[ph8]

Anyone ever have this unfortunate complication occur?

Just wondering what everyone's approach was when discussing anesthesia for their posterior spine surgeries. Do you make any emphasis to talk about it during the anesthesia consent? Do you briefly mention it in passing? Do you specifically write it down on the form/or electronically? If you do talk about it, how in depth do you go? If you do go in depth, do you also at that point go into more serious complications (i.e. cardiac arrest) that may also occur from any anesthetic? Have any patients gotten the info and been like "NO THANKS!"? And do your surgeons mention in their consent/explanation of outcomes from the surgery?

Sorry for the million questions, just trying to get a feel of what everyone else's practices are.

Heard several stories from colleagues about post-op vision loss in spine pt's.

As a resident, I discussed this with the pt in pre-op and did my best to reassure them that I would work to prevent it from occurring. To the best of my memory, almost every pt was visibly surprised to hear about this potential complication....based on this reaction, I'd venture the guess that the surgeons did not mention it. In my current work environment, I'm rarely doing these cases.

 

[deleted171991]

This is an anesthetic complication until proven otherwise (e.g. there was so much surgical bleeding that most anesthesiologists couldn't have kept up with it).

Now one (e.g. APSF) can argue that it's such a significant complication that the patient shouldn't find out about it only on the day of surgery, so the topic should be broached by the surgeon.

 

[sigrhoillusion]

This is an anesthetic complication until proven otherwise (e.g. there was so much surgical bleeding that most anesthesiologists couldn't have kept up with it).

Now one (e.g. APSF) can argue that it's such a significant complication that the patient shouldn't find out about it only on the day of surgery, so the topic should be broached by the surgeon.

Is it realy an "anesthesia" complication though? Or is it just the fact that the patient's are under anesthesia when they are put prone on their bellies/faces for 6+ hours, and lose 2+ liters of blood and get so much fluid put back in? Anesthesia is more of a confounding issue... I'm sure it adds to the risk, but hypothetically if somehow we were able to do the same procedures without anesthesia, would they still have the same risk? It's like we're along for the ride as the surgeons man the roller coaster.

 

[BLADEMDA]

Is it realy an "anesthesia" complication though? Or is it just the fact that the patient's are under anesthesia when they are put prone on their bellies/faces for 6+ hours, and lose 2+ liters of blood and get so much fluid put back in? Anesthesia is more of a confounding issue... I'm sure it adds to the risk, but hypothetically if somehow we were able to do the same procedures without anesthesia, would they still have the same risk? It's like we're along for the ride as the surgeons man the roller coaster.

That's out job- to keep the patient from falling out of the roller coaster while it runs at high speed.

 

[leaverus]

This is an anesthetic complication until proven otherwise

Wrong. It's a multifactorial complication until proven otherwise.

That's out job- to keep the patient from falling out of the roller coaster while it runs at high speed.

ok, as long as you're going with a weird analogy: you're saying if the roller coaster passenger hits their head during the ride, it's the seatbelt's fault.

the truth is we really don't know all the factors that result in povl, but the way i say it -> pt goes to surgeon, surgeon advises surgery; therefore surgeon details risks of proposed procedure, including povl, because if the pt werent having surgery their risk for any complications would be zero.

sure, if we ALSO mention it at preop visit i have no problem with it, but it's not primarily our responsibility.