February FY22

[kristenhorsman]

This month's journal article is presented by Anne McNulty. The article discusses the etiology and risk factors for postoperative vision loss.

Please follow this link and answer the following 2 questions:

1.Do you discuss POVL with your patients when you are obtaining consent? If your patient has existing risk factors for POVL do you include this in the timeout and discuss them with the surgeon?


2.What intraoperative strategies do you use to prevent ischemic optic neuropathy?

[Anne McNulty CRNA]

Pt that brought me to suggest this article was having robotic prostate surgery. The patient was also a physician and was fully aware of the risk to his vision. I discussed the pt's concern at time out. The surgeon co-operated by reducing the steep t-bird position as soon as he was able to visualize the operative areas. The second case was also a glaucoma pt. He was much larger and visualizing the operative area required a greater amount of t-bird. Keeping the blood pressure within 20% of normal limits is helpful. When the table is level for removal of the prostate, I give a greater volume of fluid needed to help prevent the foley catheter from clotting. A shorter operative time is beneficial for the pt. Some institutions use a tonometer and measure intraocular pressure and give eye drops to lower pressure during the surgery. I cannot ever imagine this happening at JHU. Vigilance in the prone position never ends.

[LarSharVeA Bailey]

This article is a great reminder of one of the most infrequent, yet dreadful, omniscient threats of having surgery in not only the prone position, but steep trendelenburg. I do not discuss POVL when obtaining consent. I feel this is a particle in the rabbit hole best discussed by those that boasts the medical degree. I have discussed it with the surgeon upon request of decreasing the MAP id est the issue with doing that is the patient can wake up blind.

I adhere to much of what has been recommended in the article to prevent POVL: keep blood pressure within baseline (20% for pts with a history of htn, and 30% for those with no such history), maintain hemoglobin greater than 10 which is the recommendation when there is active bleeding such is the case for a lot of our spines, and although this seems to be noncontributory, I assure that there is no pressure on the orbit.

[Tracey Trainum]

This article is a great reminder that POVL is a realistic complication of surgeries in the prone position. I only work in the ambulatory setting but as bigger cases and sicker patients are being pushed into the ambulatory setting it is a potential complication that every provider needs to consider. I do not routinely discuss POVL with my patients. However, I have in the past discussed it when doing anesthesia for bigger/prone cases such as spines. Including the surgeon in the discussion as well as discussing the potential for POVL in the time out are great ideas to help ensure optimal patient outcome. Being cognizant of the risk factors mentioned in the article- male sex, obesity, wilson frame, longer surgical duration, greater EBL, and lower percent of colloid in non-blood fluid administration is also very important. In the ambulatory setting, maintaining optimal BP and awareness of surgical time/blood loss are important factors in minimizing POVL in this setting.

[aileenm4]

1. I will discuss POVL as a rare complication for complex patients, long cases, neuromuscular spine cases, expected increase EBL, however reading this atricle it was interesting that POVL happened in a few healthy patients with no coexisting diseases. I do beliecve that this shopuld be a team discussion and collaboration as surgeons need to be involved
2. strategies that we implement is, using the Jackson table where the abdomen hangs freely, communication of hypotension and discussipon of need to maination adequate BP, use of TXA bolus and infusions for dec rease in EBL, use of cell saver

[Soo-Ok Kim]

1. No, I don't discuss this phenomena with pt specifically, nor include time out process. it is an interesting rare phenomenon reminding us to think about the possible risk factors for this.

2.Keeping BP within at least 20% of baseline, decrease the magnitude of t-berg, minimize blood loss/fluid resuscitation

[Amy Swank]

1. Since I work in ambulatory and haven’t done a big spine case in the prone position, I have not had a chance to discuss this potential serious, life altering risk factor with a patient with the incidence of ischemic optic neuropathy.
2. Regarding what introoperative strategies used to prevent ischemic optic neuropathy that would include maintaining or avoiding deliberate hypotension, anemia, prolonged duration of surgical time, the prone position, elevated venous pressure as they are most likely the contributing factors.