This case highlights the effect of adjustments in clinical decision making on patient outcomes during the COVID era in an ambulatory surgery center (ASC). The key issues addressed are patient management, changes in decision making for general anesthesia vs. monitored anesthesia care (MAC), and the use of simulation to educate personnel. Cognitive aids such as safety checklists and an office-based anesthesia curriculum provide a framework for optimizing patient care in this setting.
Ophthalmic surgery is a common procedure performed in the United States under MAC with local anesthesia. In the COVID era, providers chose MAC with the use of peripheral nerve blocks to minimize the added safety risk of aerosol generating procedures (AGP) associated with general anesthesia. General anesthesia decreases the requirement for local anesthesia. Regardless of the choice of anesthesia, the use of local anesthesia presents a risk of local anesthetic systemic toxicity, which require a readily available written emergency protocol for immediate treatment and transfer to a tertiary care center. In addition, ongoing education of these protocols to all personnel is crucial/essential.
An 85-year-old, 63 kg female with a history of macular degeneration presented for her second right sided vitrectomy. She had a prior successful vitrectomy under general anesthesia before COVID where general anesthesia was chosen due to surgeon’s preference at our institution and for duration of procedure. On this second procedure during the COVID era, MAC was chosen to minimize the risk of an aerosolizing procedure and this plan was agreed upon by the surgical and anesthesia teams. The patient was brought into the operating room with standard ASA monitors applied. Premedications of 1 mg midazolam and 50 mcg remifentanil were given, and the surgeon’s preference was to perform a retrobulbar block with 6 ml of a mix of 1% lidocaine, 0.375% bupivacaine in a 50: 50 mixture, as well as 5 units of hyaluronidase. The block was performed but due to inadequate akinesis, he supplemented the block with an additional 6 ml of the previously mentioned block mixture. Aspiration of heme or CSF was negative, and the total local anesthetic amount was under the toxic dose. but shortly the patient became unresponsive and started to experience tonic-clonic seizure activity. The patient was reassessed and subsequently found to be pulseless so cardiopulmonary resuscitation, intubation, and intralipid 1.5 mL/kg bolus were provided to the patient, followed by more intralipid at 0.25 ml/kg/min (400 mg total dose). The patient achieved return of spontaneous circulation, was stabilized, and transported by ambulance to an ICU where she improved overnight and was extubated the following day without any residual complications. A few weeks later, the patient returned for the eye surgery and had an uneventful general anesthetic in a similar fashion to her first retina surgery.
Local anesthetic systemic toxicity (LAST) is an adverse event associated with an ever-increasing prevalence as more regional anesthesia is utilized with an incidence currently estimated to be 0.03%, or 0.27 episodes per 1,000 peripheral nerve blocks across all healthcare settings.3 Outpatient surgery centers can perform a great deal of these surgeries safely under monitored anesthesia care with reliable discharges.4 A survey of ophthalmologists suggested that seventy-six percent of the participants reported using local anesthesia, every day, but 56.7% had received no specific training on this subject.5 The use of 20% intravenous lipid emulsion therapy for toxicity was known by 65% of the physicians, but only 1 participant stated having used it previously.5
Our case presents a unique situation in the COVID Era due to a change in the decision-making process regarding safety concerns and the choice of anesthesia, which led to an unfavorable outcome. The decision to undertake MAC rather than general anesthesia was predominately chosen due to change in policies during the COVID era to minimize the risk of airway manipulation and a potential aerosol generating procedure. Regarding LAST and other life-threatening situations, ambulatory surgery centers must have a detailed emergency policy procedure plan in place to manage and expeditiously transfer these patients to a tertiary care setting with personnel prepared to continue resuscitation. The Institute for Safety in Office-Based Surgery (ISOBS) has a safety checklist for office-based surgery6 and also an emergency manual.7 This consists of an introduction, setting, operation, before discharge and post procedure satisfaction (i.e., survey) with the patient and practitioner (Figure 1). This detailed checklist ensures that multiple safeguards have been reviewed before, during, and after the patient has had their procedure. Communication between the surgeon, nursing, anesthesia teams, and office staff is prudent especially in the ambulatory surgery center or office-based setting with limited resources and personnel. With prevalence of COVID during the pandemic, what is the safest anesthetic choice for patients and personnel? MAC obviates the need of performing an aerosolizing procedure (i.e., endotracheal intubation for general anesthesia).7 This presents a difficult situation if conversion to general anesthesia is needed. Operating room personnel would have to scramble for the necessary personal protective equipment which delays cases leading to undue stress for providers and patients. There is also a 20-minute waiting period for any individual leaving the operating room after intubation or extubation is performed.8 This can lead to lengthy delays for other patients and increased resource utilization.
Another important educational undertaking is incorporating a medical simulation program which involves OR staff, nursing, surgeons, and anesthesia professionals.9 Some of the vital skills that can be learned from simulation sessions included rapid communication, delegation of tasks, location of emergency materials, providers scope of practice, and logistics of transport to tertiary care centers.10 It should be noted that having a clear emergency action plan with cognitive aids streamlines a stressful process to make it more manageable for all individuals involved.
The COVID era has led to significant changes in the mindset of how to perform anesthesia safely for patients and to minimize risk to staff. These COVID safety considerations have produced additional risks as presented in our case. Cases that would typically be performed under general anesthesia may be attempted under MAC which can present its own series of challenges, such as LAST seen in the case described. Education through simulation scenarios and reviewing checklists ensures that group members will be able to mobilize a quick and effective response in a stressful situation.
Justin P. Benoit, DO is an Instructor of Anaesthesia at Harvard Medical School, Department of Anesthesiology, Mass Eye and Ear Infirmary, Boston, MA, 02114
Fred E. Shapiro DO, Associate Professor of Anaesthesia at Harvard Medical School, Department of Anesthesia, Mass Eye and Ear Infirmary, Boston, MA, 02114
Neither author has any conflict of interest with this manuscript
- Macias, A. and Shapiro, FE. A 20/20 View of Ophthalmic Anesthesia: A Reflective Lens Aimed to Envision the Future. APSF Newsletter June 2020; 36: 101-104.
- Mavrakanas NA, Stathopoulos C, Schutz JS. Are ocular injection anesthetic blocks obsolete? Indications and guidelines. Curr Opin Ophthalmol. 2011;22 :58-63. doi:10.1097/ICU.0b013e328341426f
- Macias, AA, Bayes J, McGoldrick, KE. Anesthesia for elective eye surgery. UpToDate. 2021. Accessed December 14, 2021.
- Urfalıoğlu A, Urfalıoğlu S, Öksüz G. The Knowledge of Eye Physicians on Local Anesthetic Toxicity and Intravenous Lipid Treatment: Questionnaire Study. Turk J Ophthalmol. 2017;47 :320-325. doi:10.4274/tjo.79446
- El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018;11:35-44. Published 2018 Aug 8. doi:10.2147/LRA.S154512
- Osman BM, Shapiro FE. Educating the Next Generation: A Curriculum for Providing Safe Anesthesia in Office-Based Surgery. APSF Newsletter. 2020: 35; 53-56.
- Young S, Pollard RJ, Shapiro FE. Pushing the Envelope: New Patients, Procedures, and Personal Protective Equipment in the Ambulatory Surgical Center for the COVID-19 Era. Adv Anesth. 2021;39:97-112. doi:10.1016/j.aan.2021.07.006
- Young S, Osman BM, Urman RD, Shapiro FE. Patients, procedures, and PPE: Safe office-based anesthesia recommendations in the COVID-19 era. Best Pract Res Clin Anaesthesiol. 2021;35:415-424. doi:10.1016/j.bpa.2020.11.006
- Ritt RM, Bennett JD, Todd DW. Simulation Training for the Office-Based Anesthesia Team. Oral Maxillofac Surg Clin North Am. 2017;29 :169-178. doi:10.1016/j.coms.2016.12.006
- Shapiro FE, Pawlowski JB, Rosenberg NM, et al. The use of in-situ simulation to improve safety in the plastic surgery office: a feasibility study. Eplasty. 2014;14:e2. Published 2014 Jan 9.