- Email: [email protected]
Eye Protection in Liver Transplantation Patients Under General Anesthesia
Eye Protection in Liver Transplantation Patients Under General Anesthesia S.-C. Yanga, H.-Y. Leea, C.-L. Chenb, C.-J. Huanga, C.-H. Wanga, K.-W. Chenga, S.-C. Wua, T.-H. Shiha, C.-E. Huanga, Y.-E. Leea, B. Jawana, S.-E. Juanga, and H.-F. Lua,* a
Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; and bDepartment of Liver Transplantation Program and Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
ABSTRACT Background. Opsite (Smith & Nephew, Hull, UK) is widely used in wound care but its use in eye protection against corneal abrasion during major surgery is rarely reported. The purpose of the current study is to compare the effectiveness of using Opsite in eye protection with either wet gauze alone or with wet gauze following application of eye ointment in patients undergoing living donor liver transplantation (LDLT). Methods. This is a prospective, double-blinded, randomized controlled trial. Forty-one patients undergoing liver transplantation were enrolled. One eye of each patient was protected with sterile gauze soaked with normal saline solution and covered with Opsite. Duratears (ALCON, Fort Worth, Tex, United States) ointment was applied to the other eye before covering it with sterile wet gauze and Opsite (ointment group). The corneal examination was carried out after fluorescein staining before and at the end of surgery by the same doctor. A Student t-test and a c2 test were used for the statistical analyses. Results. Forty-one patients with 82 eyes were observed in this study. No corneal epithelial defects were found in either the normal saline group or the ointment group. Conclusion. Opsite combined with wet gauze with or without additional eye ointment provided 100% protection against corneal abrasion in patients undergoing LDLT.
P
ATIENTS under general anesthesia (GA) are at increased risk of exposure keratopathy due to the impairment of the protective corneal reflex and decreased basal tear production [1]. The incidence of corneal epithelial defects during GA has drastically decreased from 44% [2] in unprotected eyes to 2.1% in protected eyes [3]. The aim of the study is to compare the effectiveness in the protection of the corneal abrasion by two new methods of eye care using Opsite (Smith & Nephew, Hull, UK) and Tegaderm dressings (3M, St. Paul, Minn, United States); one, combined with wet gauze alone, and two, with the addition of Duratears (ALCON, Fort Worth, Tex, United States) ointment with the wet gauze. PATIENTS AND METHODS This prospective, randomized, double-blind study was approved by the Institutional Review Board for Human Studies of Chang Gung Memorial Hospital (99e0695A3) and written informed consent was ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 2651e2653 (2018)
obtained from the study subjects. Both corneas of each patient were examined using fluorescein staining (Haag-Streit, Koeniz, Switzerland) 1 day before and at the end of the operation by the same doctor. Patients with a history of a previous ophthalmic disease or epithelial defects identified by preoperative fluorescein examination were excluded in this study. GA was administered as previously reported [4]. After anesthesia was induced, one of the patient’s eyes was protected with gauze soaked in sterile normal saline and covered with Tegaderm dressings (the normal saline group), while the other eye was further protected with the addition of Duratears ointment before being
The first two authors contributed equally to this work. *Address correspondence to Hsiao-Feng Lu, MD, Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Taiwan, No. 123, Ta-Pei Rd, 83301 Niao Song, Kaohsiung, Taiwan (R.O.C.). Tel: þ886 77317123; Fax: þ886 77318762. E-mail: [email protected] 0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.02.202
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YANG, LEE, CHEN ET AL
DISCUSSION
Table 1. Patients’ Characteristics Age (y) Weight (kg) Height (cm) Sex Anesthesia duration (h) Blood loss amount (mL) Ascites amount (mL) LPR transfusion (mL) FFP transfusion (mL) 5% albumin transfusion (mL) Crystalloid transfusion (mL) Incidence of chemosis Number of corneal abrasions from the N/Sprotected group Number of corneal abrasions from Duratearsprotected group
53.0 7.0 67.2 10.6 164 7.3 Male ¼ 32; female ¼ 9 13.5 1.7 4039 5230 2282 3692 2706 3760 848 1155 2557 2117 11,100 4154 16/41 (39%) 0/41 0/41
Abbreviations: FFP, fresh frozen plasma; LPR, leukocyte poor red blood cell; N/S, normal saline.
covered with wet gauze and finally sealed with Tegaderm dressings (Ointment group). This management was randomized and blinded by the nurse anesthetist and the examining doctor, who examined each patient’s eyes before and at the end of the surgery, did not know which eye protection method was used. For statistical analysis, a Student t-test and a c2 test were applied to compare the two groups. Any difference was considered significant when the P value was < .05.
RESULTS
Seventy-one LDLTs were performed from July 2010 to March 2011. We obtained informed consent from 42 patients, but one was excluded due to a previous corneal lesion in his right eye. A total of 41 patients (82 eyes) were finally enrolled in this study. The normal saline group was designated Group I (GI) and the ointment group was designated Group II (GII). Table 1 shows the patients’ characteristics. None of the eyes in either group showed corneal epithelial defects preoperatively or postoperatively. Conjunctival chemosis was observed in 16 patients in both eyes (Table 1). None of the patients experienced pain, blurred vision, or other complications postoperatively. Both methods showed excellent results in eye protection during liver transplantation.
Fig 1. One eye was protected with pure wet gauze, while the other eye was protected with ointment before covering with wet gauze. Both eyes were finally sealed with Opsite.
The presence of a corneal reflex associated with the ability to maintain eye closure and secretion of basal eye tears in conscious patients are mandatory in protecting the cornea against injury. GA decreases not only the production of eye tears [5] but also impairs the corneal reflex, which can lead to impaired eyelid closure, resulting in lagophthalmos, which is known to be an important contributing risk factor for corneal injury [2]. Indeed, corneal abrasion is a common eye complication during GA [2] and accounts for 3e8% of malpractice claims in the United States [6]. It can and should be prevented [2]. Nowadays, patients’ eyes are routinely protected during GA. Applying eye ointments, taping the eyelids, covering the eyes with gauze, and using moisture chambers [7] are all effective means of preventing corneal abrasions [7]. However, these methods are not sufficient to meet the special needs of patients undergoing liver transplantation. Owing to its long duration, liver transplantation presents a lot of complications that must be taken into consideration, eye complications being one of them. In addition, liver transplantation patients usually have coagulopathies, and because the surgery entails manipulation of the major abdominal vessels, massive bleeding is not unlikely, requiring timely massive blood transfusions and fluid resuscitations [4]. These massive fluid shifts may cause conjunctival chemosis, which may enhance the lagophthalmos. The mean blood loss of our patients was 4039 5230 mL. Almost all patients received massive fluid resuscitation (Table 1). Sixteen of the 41 patients (39%) had severe conjunctival chemosis at the end of the operation. Blood mixed with nasal secretions and gastric contents may be encountered during massive bleeding, which may migrate to the eyes and get in contact with the tape or gauze. The current study was designed after witnessing a complication (the eyes being contaminated by blood coming from the nose and the mouth) in 1 patient. The benefits of fluorescein staining examination are as follows: 1. that it can be performed at any time, without requiring cooperation from the patient; and 2. it is sensitive and objective [8]. Our current results show that no corneal abrasion was observed in either group using fluorescein staining. What is new in this current study is the utilization of Opsite to cover the eyes. When the Opsite was removed at the end of the operation, we found that the sterile wet gauze used to cover the eyelids was still wet and warm. This indicates that the Opsite prevented the wet gauze from drying out by evaporation during the 13-hour operation (Fig 1), allowing it to provide sufficient moisture for the eye for as long as the Opsite was tightly sealed around it. The eye protection provided by op site is much like the moist conditions provided by a moisture chamber [7]. Opsite is a transparent polyurethane membrane that creates a moist wound environment by retaining wound exudates. It is gas- and water-vapor-permeable, but impermeable to bacteria and water [9]. It is widely used to cover wounds [9], but using it as eye protection is rarely reported. Opsite is very adhesive and putting it directly on
EYE PROTECTION IN TRANSPLANT PATIENTS
the eyelid may not be suitable, as a corneal abrasion or corneal tear may occur as a result of inadvertent contact of the adhesive tape with the cornea [10]. Covering the eye with wet gauze between the eyelids and applying Opsite, as described, can prevent such a complication. CONCLUSION
Using Opsite to cover the eyes with wet gauze with or without ointment provided excellent eye protection in patients undergoing LDLT. No corneal abrasion was observed; this was confirmed by fluorescein examination as well as by post-anesthesia interviews. REFERENCES [1] Snow JC, Kripke BJ, Norton ML, Chandra P, Woodcome HA. Corneal injuries during general anesthesia. Anesth Analg 1975;54:465e7. [2] Batra YK, Bali IM. Corneal abrasions during general anesthesia. Anesth Analg 1977;56:363e5.
2653 [3] Schmidt P, Boggild-Madsen NB. Protection of the eyes with ophthalmic ointments during general anaesthesia. Acta Ophthalmol (Copenh) 1981;59:422e7. [4] Liao HL, Chen CL, Wang CH, Huang CJ, Cheng KW, Wang CC, et al. The method and accuracy of documentation of intraoperative fluids management in liver transplantation recipients. Ann Transplant 2011;16:34e8. [5] Cross DA, Krupin T. Implications of the effects of general anesthesia on basal tear production. Anesth Analg 1977;56: 35e7. [6] Gild WM, Posner KL, Caplan RA, Cheney FW. Eye injuries associated with anesthesia: a closed claims analysis. Anesthesiology 1992;76:204e8. [7] Rosenberg JB, Eisen LA. Eye care in the intensive care unit: narrative review and meta-analysis. Crit Care Med 2008;36: 3151e5. [8] Wilson SA, Last A. Management of corneal abrasions. Am Fam Physician 2004;70:123e8. [9] Aly R, Bayles C, Maibach H. Restriction of bacterial growth under commercial catheter dressings. Am J Infect Control 1988;16: 95e100. [10] White E, Crosse MM. The etiology and prevention of peri-operative corneal abrasions. Anaesthesia 1998;53: 157e61.
Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; and bDepartment of Liver Transplantation Program and Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
ABSTRACT Background. Opsite (Smith & Nephew, Hull, UK) is widely used in wound care but its use in eye protection against corneal abrasion during major surgery is rarely reported. The purpose of the current study is to compare the effectiveness of using Opsite in eye protection with either wet gauze alone or with wet gauze following application of eye ointment in patients undergoing living donor liver transplantation (LDLT). Methods. This is a prospective, double-blinded, randomized controlled trial. Forty-one patients undergoing liver transplantation were enrolled. One eye of each patient was protected with sterile gauze soaked with normal saline solution and covered with Opsite. Duratears (ALCON, Fort Worth, Tex, United States) ointment was applied to the other eye before covering it with sterile wet gauze and Opsite (ointment group). The corneal examination was carried out after fluorescein staining before and at the end of surgery by the same doctor. A Student t-test and a c2 test were used for the statistical analyses. Results. Forty-one patients with 82 eyes were observed in this study. No corneal epithelial defects were found in either the normal saline group or the ointment group. Conclusion. Opsite combined with wet gauze with or without additional eye ointment provided 100% protection against corneal abrasion in patients undergoing LDLT.
P
ATIENTS under general anesthesia (GA) are at increased risk of exposure keratopathy due to the impairment of the protective corneal reflex and decreased basal tear production [1]. The incidence of corneal epithelial defects during GA has drastically decreased from 44% [2] in unprotected eyes to 2.1% in protected eyes [3]. The aim of the study is to compare the effectiveness in the protection of the corneal abrasion by two new methods of eye care using Opsite (Smith & Nephew, Hull, UK) and Tegaderm dressings (3M, St. Paul, Minn, United States); one, combined with wet gauze alone, and two, with the addition of Duratears (ALCON, Fort Worth, Tex, United States) ointment with the wet gauze. PATIENTS AND METHODS This prospective, randomized, double-blind study was approved by the Institutional Review Board for Human Studies of Chang Gung Memorial Hospital (99e0695A3) and written informed consent was ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 2651e2653 (2018)
obtained from the study subjects. Both corneas of each patient were examined using fluorescein staining (Haag-Streit, Koeniz, Switzerland) 1 day before and at the end of the operation by the same doctor. Patients with a history of a previous ophthalmic disease or epithelial defects identified by preoperative fluorescein examination were excluded in this study. GA was administered as previously reported [4]. After anesthesia was induced, one of the patient’s eyes was protected with gauze soaked in sterile normal saline and covered with Tegaderm dressings (the normal saline group), while the other eye was further protected with the addition of Duratears ointment before being
The first two authors contributed equally to this work. *Address correspondence to Hsiao-Feng Lu, MD, Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Taiwan, No. 123, Ta-Pei Rd, 83301 Niao Song, Kaohsiung, Taiwan (R.O.C.). Tel: þ886 77317123; Fax: þ886 77318762. E-mail: [email protected] 0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.02.202
2651
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YANG, LEE, CHEN ET AL
DISCUSSION
Table 1. Patients’ Characteristics Age (y) Weight (kg) Height (cm) Sex Anesthesia duration (h) Blood loss amount (mL) Ascites amount (mL) LPR transfusion (mL) FFP transfusion (mL) 5% albumin transfusion (mL) Crystalloid transfusion (mL) Incidence of chemosis Number of corneal abrasions from the N/Sprotected group Number of corneal abrasions from Duratearsprotected group
53.0 7.0 67.2 10.6 164 7.3 Male ¼ 32; female ¼ 9 13.5 1.7 4039 5230 2282 3692 2706 3760 848 1155 2557 2117 11,100 4154 16/41 (39%) 0/41 0/41
Abbreviations: FFP, fresh frozen plasma; LPR, leukocyte poor red blood cell; N/S, normal saline.
covered with wet gauze and finally sealed with Tegaderm dressings (Ointment group). This management was randomized and blinded by the nurse anesthetist and the examining doctor, who examined each patient’s eyes before and at the end of the surgery, did not know which eye protection method was used. For statistical analysis, a Student t-test and a c2 test were applied to compare the two groups. Any difference was considered significant when the P value was < .05.
RESULTS
Seventy-one LDLTs were performed from July 2010 to March 2011. We obtained informed consent from 42 patients, but one was excluded due to a previous corneal lesion in his right eye. A total of 41 patients (82 eyes) were finally enrolled in this study. The normal saline group was designated Group I (GI) and the ointment group was designated Group II (GII). Table 1 shows the patients’ characteristics. None of the eyes in either group showed corneal epithelial defects preoperatively or postoperatively. Conjunctival chemosis was observed in 16 patients in both eyes (Table 1). None of the patients experienced pain, blurred vision, or other complications postoperatively. Both methods showed excellent results in eye protection during liver transplantation.
Fig 1. One eye was protected with pure wet gauze, while the other eye was protected with ointment before covering with wet gauze. Both eyes were finally sealed with Opsite.
The presence of a corneal reflex associated with the ability to maintain eye closure and secretion of basal eye tears in conscious patients are mandatory in protecting the cornea against injury. GA decreases not only the production of eye tears [5] but also impairs the corneal reflex, which can lead to impaired eyelid closure, resulting in lagophthalmos, which is known to be an important contributing risk factor for corneal injury [2]. Indeed, corneal abrasion is a common eye complication during GA [2] and accounts for 3e8% of malpractice claims in the United States [6]. It can and should be prevented [2]. Nowadays, patients’ eyes are routinely protected during GA. Applying eye ointments, taping the eyelids, covering the eyes with gauze, and using moisture chambers [7] are all effective means of preventing corneal abrasions [7]. However, these methods are not sufficient to meet the special needs of patients undergoing liver transplantation. Owing to its long duration, liver transplantation presents a lot of complications that must be taken into consideration, eye complications being one of them. In addition, liver transplantation patients usually have coagulopathies, and because the surgery entails manipulation of the major abdominal vessels, massive bleeding is not unlikely, requiring timely massive blood transfusions and fluid resuscitations [4]. These massive fluid shifts may cause conjunctival chemosis, which may enhance the lagophthalmos. The mean blood loss of our patients was 4039 5230 mL. Almost all patients received massive fluid resuscitation (Table 1). Sixteen of the 41 patients (39%) had severe conjunctival chemosis at the end of the operation. Blood mixed with nasal secretions and gastric contents may be encountered during massive bleeding, which may migrate to the eyes and get in contact with the tape or gauze. The current study was designed after witnessing a complication (the eyes being contaminated by blood coming from the nose and the mouth) in 1 patient. The benefits of fluorescein staining examination are as follows: 1. that it can be performed at any time, without requiring cooperation from the patient; and 2. it is sensitive and objective [8]. Our current results show that no corneal abrasion was observed in either group using fluorescein staining. What is new in this current study is the utilization of Opsite to cover the eyes. When the Opsite was removed at the end of the operation, we found that the sterile wet gauze used to cover the eyelids was still wet and warm. This indicates that the Opsite prevented the wet gauze from drying out by evaporation during the 13-hour operation (Fig 1), allowing it to provide sufficient moisture for the eye for as long as the Opsite was tightly sealed around it. The eye protection provided by op site is much like the moist conditions provided by a moisture chamber [7]. Opsite is a transparent polyurethane membrane that creates a moist wound environment by retaining wound exudates. It is gas- and water-vapor-permeable, but impermeable to bacteria and water [9]. It is widely used to cover wounds [9], but using it as eye protection is rarely reported. Opsite is very adhesive and putting it directly on
EYE PROTECTION IN TRANSPLANT PATIENTS
the eyelid may not be suitable, as a corneal abrasion or corneal tear may occur as a result of inadvertent contact of the adhesive tape with the cornea [10]. Covering the eye with wet gauze between the eyelids and applying Opsite, as described, can prevent such a complication. CONCLUSION
Using Opsite to cover the eyes with wet gauze with or without ointment provided excellent eye protection in patients undergoing LDLT. No corneal abrasion was observed; this was confirmed by fluorescein examination as well as by post-anesthesia interviews. REFERENCES [1] Snow JC, Kripke BJ, Norton ML, Chandra P, Woodcome HA. Corneal injuries during general anesthesia. Anesth Analg 1975;54:465e7. [2] Batra YK, Bali IM. Corneal abrasions during general anesthesia. Anesth Analg 1977;56:363e5.
2653 [3] Schmidt P, Boggild-Madsen NB. Protection of the eyes with ophthalmic ointments during general anaesthesia. Acta Ophthalmol (Copenh) 1981;59:422e7. [4] Liao HL, Chen CL, Wang CH, Huang CJ, Cheng KW, Wang CC, et al. The method and accuracy of documentation of intraoperative fluids management in liver transplantation recipients. Ann Transplant 2011;16:34e8. [5] Cross DA, Krupin T. Implications of the effects of general anesthesia on basal tear production. Anesth Analg 1977;56: 35e7. [6] Gild WM, Posner KL, Caplan RA, Cheney FW. Eye injuries associated with anesthesia: a closed claims analysis. Anesthesiology 1992;76:204e8. [7] Rosenberg JB, Eisen LA. Eye care in the intensive care unit: narrative review and meta-analysis. Crit Care Med 2008;36: 3151e5. [8] Wilson SA, Last A. Management of corneal abrasions. Am Fam Physician 2004;70:123e8. [9] Aly R, Bayles C, Maibach H. Restriction of bacterial growth under commercial catheter dressings. Am J Infect Control 1988;16: 95e100. [10] White E, Crosse MM. The etiology and prevention of peri-operative corneal abrasions. Anaesthesia 1998;53: 157e61.