A Preventive intervention for rising intraocular pressure: Development of the Molloy/Bridgeport anesthesia associates observation scale
Anesthesia Department, Bridgeport Hospital/Yale New Haven Network, Connecticut, USA. AANA journal
There is increasing interest in monitoring intraocular pressure (IOP) during surgery in steep Trendelenburg position because of reported incidents of postoperative visual loss (POVL). A review of 17 patients with POVLs showed findings of eyelid edema, chemosis, and ecchymosis. The aim of this study was to link IOP tonometry measurement to an observation scale enabling caregivers to determine when to institute preventive measures to optimize ocular perfusion. The study design was a prospective repeated-measures correlation regression model. Visual assessment of presence of eyelid edema or chemosis and baseline IOP values determined the probability of when an IOP greater than 40 mm Hg (critical threshold) was reached. Both IOP and Molloy/Bridgeport Anesthesia Associates Observation Scale measures were recorded at start of surgery, 30-minute intervals, and end of surgery. Associations between IOP and facial observations were analyzed via multiple logistic regression. Significant predictors of IOP greater than 40 mm Hg were determined to be presence of chemosis and baseline IOP and significantly correlated to increasing IOP. The receiver operating characteristic curve-area under the curve score was 0.86 (standard error +/- 0.03). Caregivers can use this observation scale to assess the need and timing for IOP-normalizing interventions and possibly to prevent POVL.
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ABSTRACT: Trendelenburg positioning (TP) has a dramatic effect on the circulation and consequently, increases cerebral and intra-ocular pressure (IOP). We evaluated whether modification in TP can minimize the elevation of IOP.
This is a prospective randomised controlled study, comparing patient's IOP in TP, and "Modified-Z" TP in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALRP). The IOP, blood pressure and Endotracheal (ET) CO2, measured at the induction of anaesthesia;(T1), before positioning;(T2), TP;(T3), "Modified-Z" TP;(T4) (group 1). After pneumo-peritoneum;(T5) every 30-minutes;(T6-16), supine, cease of pneumo-peritoneum;(T17), and before awakening;(T18). We modified the TP by placing the head and shoulders horizontally.
Group 1; 29 patients in "Modified-Z" TP, and 21 patients in-Group 2, TP. No differences were found regarding patient's demographics, and surgical outcomes. Median IOP was in the low-normal range at T1-2 and increased in (T3); in group both groups. From T4 the IOP decreased and was significantly lower in group 1, by mean of 4.61mmHg (CI -6.90, 2.30), at all-time points (p<0.001). At T17 the mean IOP went down; 19.6mmHg (normal) and 24.9mmHg (hypertensive range) in Group 1, and 2 respectively. At T18 the mean IOP in both groups was 17mmHg. The blood pressure was significantly lower in Group 1, with mean reduction of 6.3mmHg systole and 4.3mmHg diastole.
Our results suggest that modifying TP during RALRP, has a significant positive effect on patient's neuro-ocular safety, by lowering the IOP and accelerating its recovery to normal range, without affecting the operation.
Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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