PATIENT STRESS IN CATARACT SURGERY

ATTEMPT TO IDENTIFICATION OF ORIGIN

The authors of this e-poster have received travel expense reimbursement from ALCON .The authors have no financial interest in the subject matter of this e-poster.

François A Blondeau MD

Le Château d’Olonne FRANCE

ASCRS San Diego March 25-29

2011

Rich Wilson Vendee Globe March 11 2009

Is a patient sedation as mandatory as usually said in cataract surgery ? This study tries to identify what can have been a factor of stress and gives some paths to avoid useless medication and heavy medical

environment

Document on next slide has to be given to patient before cataract surgery and patient signature is requested to certify that patient information on surgery is complete.

This text is very different of the text to be read on ASCRS web site :The anesthesiologist’s opinion as well as his/her presence, are described as necessaryA hospital structure is described as the environment of choice 18 risks are given among them per operative infection with a rate of 1to 3 out of 1000 surgeries

 Patient is advised :

“There is no surgery without risk”and :

“Total loss of the eye function or the eye itself may occur”.

Some patients give up the surgery.

This reading may create some images far from serenity

Methods

Author makes a retrospective survey on more than 2000 consecutive procedures of cataract surgery ( and intra vitreal injections ) performed under topical anesthesia in a French ambulatory surgical center without sedation in standard procedure.

“If you’re feeling nervous about lens replacement for your cataracts, keep in mind-modern cataract surgery is one of the safest and most effective medical procedures performed today. It helps about 3 million people each year in the U.S. alone, with an overall success rate of 98% or higher. It may also make you feel more confident if you know what you can expect every step of the way-from your initial evaluation to the day of the surgery…

Many patients ask their spouse, friend or caregiver to attend their pre-operative appointment, to serve as an extra set of ears to hear the doctor's recommendations and directions.”

ASCRS information :

Office based surgery does not induce stress as much as wide hospitalization structures do.

Once he has entered the surgery room, he is glad to recognize the voice of the nurse who gave him all the useful recommendations a few days earlier

Patient knows the face and the name of each professional  he meets at the office

2230 SURGERIES have been performed between November 26, 2006 and February 15, 2011 (39 months)  

Cataract extraction with IOL : 1801

Intravitreal injections : 429

AVERAGE AGE of PATIENTat TIME of SURGERY

72 ½FROM 25 ¾ TO 97 ¼

NO INTRACAMERAL INJECTION OF ANTIBIOTIC AT END OF SURGERY

Results :

No sedation was the standard procedure for all the patients. As next slide shows more than 100 surgeries were performed in patients with psychiatrics treatments without any change of this treatment.Nearly 150 were performed on patients with medical treatments for depression As next slide shows some where suffering of ALZEIMER, PARKINSON OR EPILEPSY A light sedation has been used for only 2 patients on their demand.

No general anesthesia had to be performed on any patient

Other associated pathologies are compiled on next slide.

Medical Outcome Measurements are Endophthalmitis or TASS rates and Patient Satisfaction.

Endophthalmitis rate = 0Toxic Anterior Segment Syndrome rate = 0

High blood presure 1412   CANCERS ( under treatment ) 37

ARYTHMY 304   CHIMIOTHERAPY 56

PACEMAKERS 61   CANCERS (Remission) 258

ANTICOAGULANTS 423   previous CHIMIOTHERAPY 139

Compensated heart failure 109      

ANGOR treaments 56   HEPATITIS B 2

previous vascular diseases 245   HEPATITIS C 5

      VIH 3

Asthma. BPCO 189   CORTICOTHERAPY 78

THORACIC SURGERY 3      

OXYGENO-THERAPY ≥18H/d 13   DIABETES 255

      INSULIN 63

Psychiatry 103   PANCREATITE 3

ANTIDEPRESSEURS 148      

         

ALZHEIMER 26   THYROID 111

PARKINSON 22      

EPILEPSY 38      

PERIPHERIC NEUROPATHY 11   RHEUMATOID 9

LSA 4   HORTON 10

A satisfaction questionnaire is given to patients following NF ISO 9001 2000 certification requirements

This questionnaire is shown on next slide Questions are about1 Quality of reception at the facility2 Waiting delay at the facility3 Quality of information given by surgeon during

appointment4 Quality of information given by staff during

appointment5 Quality of information given by staff during stay for

surgery 6 Quality of information about surgery given in written

documents 7 Quality of care before surgery8 Quality of care after surgery9 Quality of pain care during and after surgery

Suggestions Overall satisfaction

Reception at the facility reaches the best performance of quality when written information given to the patient remains a little less efficient that we had hoped .Information given by Surgeon himself, the Nurse or the staff is more efficient.Less satisfaction for waiting delay before surgery – for pupil dilatation - may be explained by stress of patient who did not received sedation but was never a factor during surgery (perception of the quality of pain care is the same than perception of quality of information).

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10%

20%

30%

40%

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Reception at the facility

Waiting delay at the facility

Information given by surgeon during appointment

Information given by staff during appointment

Information given by staff during stay for surgery

Information about surgery given in writ-ten documents

Quality of care before surgery

Quality of care after surgery

Quality of pain care during and after surgery

Overall satisfaction

Conclusion This retrospective survey demonstrates that anaesthesiology environment ( or patient sedation most of times ) is useless for cataract surgery procedures in patients even with heavy stabilized pathologies.A good information of patient ( and his closest relatives as suggested on ASCRS web site ) showing the safety and effectiveness of the procedure appears to be very efficient .Analyse shows a little advantage of direct information compared to written.A confident patient may have surgery without any sedation. This is helpful for the care of elderly patients or patients with heavy pathologies ( ASA 3 ).

Waiting time during pupil dilatation is an important factor which demands high quality of staff.