Post on 07-Jul-2020
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Kate Goldblum, CFNP Albuquerque, New Mexico
Disclosures I have no financial or other conflicts of
interest relevant to this presentation.
I do not discuss an off-label use of any commercial product in this presentation.
Evaluation for Cataract Surgery Visual acuity – near and distance Glare disability Axial length Keratometry Anterior chamber depth White-to-white distance Corneal pachymetry Lens thickness Other parameters (pupillometry, visual axis
eccentricity, retinal thickness)
Preparing the Patient Routine for us, sometimes terrifying for our
patients! What can we do to make the process less
stressful?
Visual Acuity Does the patient even need cataract
surgery? Glare disability determination Issues impacting IOL power
Patient expectations and goals Preoperative refractive correction Refractive surgery status Ability to pay for premium lenses
Measurements for IOL Power Determination IOL Master Lenstar
IOL Master Partial coherence interferometry (PCI) Captures 4 measurements
Axial length Keratometry Anterior chamber depth White-to-white distance
Lenstar Optical low coherence reflectometry (OLCR) Captures nine measurements
Axial length Keratometry Anterior chamber depth White-to-white distance Pachymetry Lens thickness Pupillometry Eccentricity of the visual axis Retinal thickness
Postoperative Vision Assess patient expectations and goals! Willing to accept spectacle wear after
surgery? Or no glasses for near, distance, or both?
Preoperative Refractive Error May affect postoperative goals Hyperopic before surgery – more likely to
accept need for near correction Myopic before surgery – more likely to
dislike need for near correction “Perfect” before surgery – post-refractive
surgery more likely to seek same “perfection”
Correction Options Intraocular lenses
Standard monofocal “Premium” lenses
Multifocal Accommodating (Crystalens) Toric Aspheric
Monovision Monofocal Multifocal (blended monovision)
Decreasing Patient Stress Spend enough time with the patient to
assess patient’s individual needs Demonstrate and project knowledge,
competence, professionalism, and empathy
Determine what the patient needs/wants to know about the process and surgery
Procedural Information You’ll check in at . . . . In the holding area . . . . In the operating room . . . . After your surgery, you’ll go . . . . Before we discharge you to go home . . . .
Sensory Information Visual – what will the patient see? Tactile – what will the patient feel? Auditory – what will the patient hear? Gustatory – what will the patient taste? Olfactory – what will the patient smell?
Preoperative Medical Clearance Assuring Patient Safety
ASORN 2012
Carol A Matthews FNP
* I have no financial or other conflicts of interest relevant to this presentation.
* I do not discuss an off-‐label use of any commercial product in this presentation.
Disclosures
* Cataract * Cornea * Glaucoma * Muscle * Pediatric * Plastics * Retina
Types of Surgery
* Surgeon * Skill level of the surgeon * Attending clean & fast * Student slower * Adaptability of surgeon * Type of anesthesia required * Length of surgery
Patient Safety Considerations
* Allergies * Difficult intubation * Hard to awaken post-‐procedure * Nausea and vomiting * Family history of anesthesia problems
Anesthesia: Prior Issues
* For risk stratification
* Is the patient acceptable candidate for ASC
* Consider all medical problems and look for RED FLAGS
History and Physical
* AIRWAY * Thick neck * Obstructive sleep apnea (OSA) * Large tongue * Small mouth * Poor mobility * History of radiation to neck * Goiter
Anesthesia Red Flags
Airway Assessment
Opens mouth normally Adults > 3 cm Children varies by age
Ability to visualize at least part of the uvula and tonsillar pillars with mouth wide open and tongue out
ASA Airway Classification
* Grade murmur * Obtain recent echocardiogram * Is patient symptomatic * Has patient received continuous care * Medication compliance
Aortic Stenosis
* Chronic kidney disease (CKD) stage * End stage renal disease (ESRD) * On dialysis * On transplant list * Obtain labs (chemistry and CBC * If on dialysis or abnormal potassium, repeat on day of
surgery
Renal Disease
* What are fasting sugars at home * HgA1c within past three months * Episodes of hypoglycemia * Comorbidities * Regular check ups with PCP
Diabetes
* How short of breath is the patient – can she * Walk across the room? * Talk without gasping? * On O2 * O2 saturation below 92 * Unable to lie flat * Paroxysmal nocturnal dyspnea (PND) * Tripod breathing
Severe COPD
* Needs recent echocardiogram * Pulmonary function tests (PFTs) * Recent follow up with treating MDs
Pulmonary Hypertension
* New onset * Rate controlled * Asymptomatic * Treated * Anti-‐coagulated * Can surgery be done while patient on anticoagulants * Do they need Lovenox bridge * If stable, can they be held
Atrial Fibrillation
* When were they placed? * Type of stent * Minimal usual wait is 6 weeks for elective cases * Drug-‐eluding stent (DES) wait is 12 months for
elective cases * If surgery is necessary, requires in-‐hospital facility
with invasive cardiology services available
Cardiac Stents
* Level * Ability to cooperate * Tactile sensitive * Previous anesthesia history * Other factors
Autism
* Type * Level * Ability to cooperate * Determine anesthesia needs
Developmental Disabilities
* Review information & determine next step * Is patient a good candidate for surgery in an ASC? * Yes – proceed & no further workup * No – need more information & action
* Order & interpret required labs * Abnormal labs * Send to PCP * Review by anesthesia prior to surgery * Patient informed
* Does patient need a “tune up” by PCP? * HTN not controlled * Increased SOB * If yes – refer back to PCP
What Next?
* New onset fibrillation * Compensated – facilitate appointment with PCP * Non-‐rate controlled * Patient needs to see PCP ASAP * Mutual decision – urgent care versus emergency
Immediate Medical Issue
* Request to maximize patient for surgery * Call or send note to treating MD to see patient;
include explanation of need * Treating provider responds * Patient stable & may proceed * Patient requires further workup
Referral to PCP or Specialist
* Borderline candidate for ASC * Questionable airway * Child with disabilities * Extremely anxious parent * Anesthesia always happy to see
Anesthesia Consult
* Collaborate with anesthesia to determine if ASC surgery is in best interest of patient * If workup indicates patient is not ASC candidate
inform surgeon & determine location * Outpatient in hospital * Rady Children’s Hospital * Inpatient
Is ASC in Patient’s Best Interest?
* Give all patients prescriptions as needed * Review instructions * Answer questions * Pediatric patients * Instructions with play therapy * Tour of surgical facility * Meet OR staff & anesthesia personnel if available
* Discharge patient to see at surgery
CONCLUSION
Kate Goldblum, CFNP Albuquerque, New Mexico
Disclosures I have no financial or other conflicts of
interest relevant to this presentation.
I do not discuss an off-label use of any commercial product in this presentation.
Schedule Information Procedure Surgeon Start time Which eye Length of procedure Availability of equipment & supplies
Schedule Considerations Patient’s needs Difficult cases last Similar cases done in succession Similar laterality done in succession Availability of equipment & instruments Allocation of appropriate amount of time
Efficiency = Cost-Effectiveness Procedure time for
various surgeries
Room turn over time (2 rooms?)
Verify surgical site in advance
Average cataract is 8-10 minutes
Average is 3-5 minutes
Prevents delays and saves times
Time Management Prepare – avoid preventable delays Speed, accuracy, thoroughness Unexpected cancellations
The Patient’s Experience Fear and/or anxiety Embarrassment Cold environment
Making a better experience Explanations, reassurance, comfort “Vocal anesthesia” and therapeutic touch Warm blanket, soothing music
Preparation OR team: surgeon, circulator, scrub,
anesthesia Surgeon preference cards Instruments, medications, equipment Special order items
High power lens Mitomycin C Special instruments Custom packs
Validate Documents Consent(s) H&P Labs/other testing Preop checklist
Staffing and Stocking Appropriate numbers and mix of staff Adequate supplies & equipment
Toxic Anterior Segment Syndrome (TASS) Acute, noninfectious endophthalmitis Anterior segment inflammation Complication of anterior segment surgery
TASS Contaminants on surgical instruments from
improper or inadequate cleaning Products introduced into eye during
surgery Irrigating solutions Ophthalmic medications Other substances
Topical ointments or antiseptic agents Talc from surgical gloves
TASS Typical presentation
Develops within 24 hours of surgery Corneal edema Accumulation of white cells in anterior
chamber
Treatment – topical steroids, NSAIDs or both
Prevention of TASS Product recalls and/or communication Compounding alerts Appropriate management of intraocular
surgical instruments
Surgical Instrument Care Recommendations 1-5 Adequate time for cleaning/sterilization Follow manufacturers’ directions Not allowing viscoelastic solutions to dry
on instruments Transport opened instruments from OR in
closed container for immediate cleaning Use disposable cannulas and tubing
whenever possible
Surgical Instrument Care Recommendations 6-10 Do not re-use devices labeled for single-use Clean intraocular instruments separately from
non-intraocular instruments Use detergents properly and rinse instruments
thoroughly after cleaning/final rinse with sterile distilled or deionized water
Proper use of ultrasonic cleaner (when used) Appropriate manual cleaning processes
Surgical Instrument Care Recommendations 11- 17 Appropriate rinsing processes Dry instruments with lumens after rinsing
with forced or compressed air Follow special instructions for phaco & I/A
handpiece, I/A tips, & inserters Use proper processes for reusing woven
materials Verify cleanliness & integrity of instruments Use appropriate sterilization methods/
processes
Surgical Instrument Care Recommendation 17
Implement administrative controls: a) written policies & procedures, b)purchase of adequate numbers of instruments sets, & c) provision of appropriate education on all recommendations
Recommended practices for cleaning and sterilizing intraocular surgical instruments (2007). The Journal of Cataract and Refractive Surgery, 33, 1096-1100.
E L E T H I A D E A N , R N , M B A , P H D P A T R I C I A A . L A M B R N , M N , C N S , C R N O
Discharge to Home
© 2012 ASC Compliance, LLC
Disclosures
We have no financial or other conflicts of interest relevant to this presentation.
We do not discuss off-label use of any commercial product in this presentation.
© 2012 ASC Compliance, LLC
DISCHARGE PLANNING
Discharge planning begins when surgery is scheduled.
Identify patient education needs and implement resources as needed (home care, social services referrals, etc.)
Inform the patient and family Prepare them as events unfold What to expect at each step
© 2012 ASC Compliance, LLC
Peri Operative Care
Begins before the patient arrives (admission), pre-operative area, surgical event, postop care, discharge planning & discharge
Considerations: Elderly adults are at greater surgical risk Preoperative meds may or may not be reordered Identify postoperative needs (responsible adult
postoperatively)
© 2012 ASC Compliance, LLC
Vital Information for Discharge
Care of the wound, incision, dressing
Medication reconciliation:
Actions and possible reactions of medications
Should patient resume all preoperative medications
Follow-up appointment
Activities allowed - when and what • Exercise, sexual activity, driving the car, return to work, • leisure activities
© 2012 ASC Compliance, LLC
More Vital Information
Emergency phone numbers
What to expect in the first few days or hours postoperatively
Verbal and written discharge instructions
© 2012 ASC Compliance, LLC
More Vital Information
Remember that communication breakdowns cause 75% of problems
“The biggest problem in communication is the illusion that it has taken place.”
- George Bernard Shaw
© 2012 ASC Compliance, LLC
Regulatory Standards
Be familiar with applicable state, federal and accreditation regulations
Policies & procedures should reflect current practice
Remember…if it is written it must be done!
© 2012 ASC Compliance, LLC
Questions ? Discussion?
© 2012 ASC Compliance, LLC