• Intraoperative and Postoperative Anesthesia Management of Postoperative Visual Loss in Robotic Surgeries

      Louis, Kesiah D.; Gutchell, Veronica (2020-05)
      Problem Statement & Purpose: Postoperative vision loss (POVL) associated with robotic surgeries occurs at a rate of 1.9 events per 10,000 cases (Alwon & Hewer, 2016). Patients who have suffered from this event experience an increased hospital stay of 8.6 days as oppose to the standard 4.1 days. In addition, those that suffer ocular complications experience increased cost expenditures of $49,532 from $22,697 (Alwon & Hewer, 2016). Currently there is no standard of care in place at this level II trauma center in Baltimore, MD. Although the occurrence of this event is rare, this clinical practice guideline (CPG) was developed to effectively care for patients undergoing robotic surgery to prevent POVL. Methods: Development of the CPG was a collaborative effort amongst an expert panel that consisted of a chief anesthesiologist, a chief certified registered nurse anesthetist, a clinical site representative, and 2 Doctors of Nursing practice (DNP) students. A thorough evidence review was conducted, and an initial CPG was drafted. The draft CPG was presented to the expert panel where the AGREE II tool was used to evaluate the quality of the CPG. Modifications were made based on AGREE II tool feedback. The final CPG was presented to anesthesia providers during grand rounds where practitioner feedback questionnaires (PFQ) were disseminated. PFQ results were reviewed and analyzed. The final CPG was assembled and disseminated to the facility. Results: Each domain of the AGREE II tool received scores of higher than 85% with an overall average of 92% after modifications were made. Of the 25 PFQs received, 100% response rate was obtained from the three questions analyzed. Questions 8, 16, and 23 were analyzed and each received scores of 68%, 80%, and 76% respectively, strongly agreeing to adapt the CPG into practice. Conclusion: The CPG is a culmination of evidence-based practice recommendations to be utilized throughout the perioperative period for patients undergoing robotic surgeries. Based on the results obtained from the AGREE II tool and PFQ, the CPG was accepted by the anesthesia department. Use of this CPG provides education on POVL as well facilitates positive patient outcomes for this patient population.
    • Prevention and Management of Postoperative Vision Loss (POVL) in Patients Undergoing Procedures in Trendelenburg and Prone Positions

      Lee, Judith; Pellegrini, Joseph (2019-05)
      Background: Postoperative vision loss (POVL) is considered rare, but it is a devastating complication that can occur in any patient undergoing surgery and it is important for anesthesia providers to understand the prevention and management of POVL. It has been shown there has been an increase in prevalence of POVL in patients that are placed in prone and steep Trendelenburg (ST) positions for cardiac, spine, head and neck, and orthopedic procedures. The exact prevalence of POVL is unknown, however, permanent POVL associated with spine surgery has been reported in as many as 1 in 500 operations (0.2 percent) from data obtained from three centers that performed over 3,400 spine surgeries. The most common cause of postoperative ocular injuries usually involves corneal abrasion, which may be associated with vision loss, and increased ocular perfusion pressure (IOPP). The complications associated to POVL can be anything from transient blurring to complete permanent blindness. Patients who experience POVL spend an average of 8.6 days in the hospital, costing an average of $42,532 vs. 4.1 days costing an average of $22,697 for those unaffected. Local Problem: The purpose of this DNP project was to develop a clinical practice guideline (CPG) to decrease incidences of POVL at a community hospital in Baltimore, Maryland, (which renders nearly half of its cases in STP, during prone, laparoscopic, and robotic-assisted cases), that has reported a growing concern for management of POVL. Currently, the target institution has no uniform standard for the management of POVL. Therefore, the purpose of this CPG was to develop a standardization of the management of patients undergoing procedures in ST and prone positioning. Interventions: The CPG development consisted of two phases. Phase I (June 2018-August 2018) included the identification of the practice problem, target site, and appropriate stakeholders and their approval in assisting with the project. Barriers and project measures were developed and the initial draft of the CPG was made. The CPG was then presented to the stakeholders for feedback and revisions were made accordingly. The project was then submitted to the University of Maryland School of Nursing (UMSON) Institutional Review Board (IRB) for approval. Phase II (September 2018-April 2019) included the presentation of the CPG to the anesthesia staff members at the target site. The anesthesia staff in attendance was given a Provider Feedback Questionnaire (PFQ) to complete and was collected at the end of the meeting. The results from the PFQ was then synthesized and analyzed to make further revisions to the CPG with suggestions from the stakeholders. The final DNP project manuscript was then submitted for committee review. Results: Data obtained from the AGREE II tool and PFQ were analyzed with descriptive and correlational statistics. Each domain of the AGREE II tool was individually analyzed and showed that the overall quality of the guidelines was rated highly. Appraisers recommended the CPG for it to be presented to the target institution by receiving scores above 86%. There were a total of 24 persons attending the implementation presentation whom all received the PFQ and 100% of the PFQ was received in completion. The confidence interval was 95% after calculating the total percentage of agreement which was 74% and the standard deviation was 15%. The overall comparisons between CRNA and MD via chi-square analysis was 27.3156 with a p-value <0.01. The result was significant at p <0.05. The analysis of the PFQ demonstrated the acceptance of the CPG by both groups of anesthesia providers at the target site regardless of any differences. Conclusion: The results of the study showed that there is large positive feedback from the group towards the presented CPG. This CPG has great potential and usefulness in reducing the incidence of POVL in patients undergoing surgery at this facility by standardizing the practice. Lowering POVL incidence would mean less occurrences of potential devastating permanent damages to vision that could severely impact the patients’ quality of life.