Patient Monitoring, Patient Safety

Sedation and cataract surgery: A case for continuous electronic monitoring

By Michael Wong

“Inexplicably left alone.”

That, according to Jury Verdict Review & Analysis, is what happened to 68-year-old Marie Golubski after she was prepped and intravenously sedated for cataract surgery in June 2010. In other words, no anesthesiologist, no nurse or no ophthalmologist was present when Ms. Golubski slipped into respiratory depression.

More than 20 minutes lapsed after Ms. Golubski’s IV had been administered precedural sedation, medical staff found her unresponsive and determined that she had suffered anoxic brain injury. She was rushed to a nearby hospital for resuscitative treatment, but died there six days later. Three years after her death, Ms. Golubski’s family agreed to a $2.1-million settlement with the facility where she was supposed to have undergone what otherwise would most likely have been a successful, routine cataract procedure.

Although Ms. Golubski’s case is heartbreaking on many levels, the greatest tragedy of all is that it didn’t have to happen. Court records show that Ms. Golubski’s anesthesiologist and ophthalmologist each believed that it was the other person’s responsibility to monitor her after she was sedated. Yet, even if neither had been present after her IV was administered, Ms. Golubski’s health and safety could have been protected had she been monitored continuously with pulse oximetry for oxygenation and capnography for adequacy of ventilation. Another important clinical point is professional responsibility should be identified before any type of sedation so the accountability for the patient’s ordered monitoring is designated.

The Anesthesia Patient Safety Foundation (APSF) recently called for a paradigm shift in opioid care. In video released February 2014, titled “Opioid-Induced Ventilatory Impairment (OIVI): Time for a change in the Monitoring Strategy for Postoperative PCA Patients.”   , APSF highlighted the conclusions and recommendations that came out of a 2011 conference on opioid-induced ventilatory impairment. In the video, APSF states that continuous electronic monitoring of oxygenation and ventilation, when combined with traditional nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment.

Robert Stoelting, MD (President, APSF) emphasized the need for this shift in opioid care:

“It’s time for a change in how we monitor postoperative patients receiving opioids. We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.”

In a recent 2010 National survey of almost 200 hospitals from across the U.S., hospitals that monitor patients using patient-controlled analgesia with integrated capnography were three times more likely to have reduced adverse events and lowered healthcare expenditures.

Although continuous electronic monitoring with pulse oximetry and capnography may not be widely used within the ophthalmology speciality area today, the tragic case of Marie Golubski makes a strong argument that the time has come for it to be utilized consistently when opioids are used.

 

 

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