Lanjutan ke -2, ANESTHESIA FOR CATARACT SURGERY

  • 22/07/2021
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VII. SPECIAL CONSIDERATIONS REGARDING ANTITHROMBOTICS

The concern that patients taking antithrombotics before surgery might be at higher risk or perioperative bleeding must be balanced against the risk of stopping these drugs and increasing the risk of a life-threatening clotting complication (eg, stroke, myocardial infarction, pulmonary embolism or deep vein thrombosis). There have been several recent articles addressing this issue for patients having cataract surgery.

After reviewing multiple studies on this issue, the most widely quoted review on the perioperative use of antithrombotics by Douketis et al in 2008 recommends continuing aspirin and warfarin (Coumadin) in therapeutic doses before cataract surgery.At that time, the authors recommended continuing clopidogrel (Plavix) for patients who were at high risk of stopping it but also commented that there were few studies looking at the risks of continuing clopidogrel before cataract surgery.

However, a large retrospective study published in 2009 of patients taking aspirin, warfarin (Coumadin), and clopidogrel (Plavix) up to the time of cataract surgery found that although patients taking warfarin and clopidogrel had a slightly higher incidence of minor bleeding issues (eg, lid hematomas, subconjunctival bleeding), patients taking any of these 3 drugs did not have a higher incidence of sight-threatening bleeding complications (eg, retrobulbar or intraocular hemorrhage) from eye blocks or cataract surgery.

Patients taking aspirin and clopidogrel for the most common type of cardiac stent insertion (drug eluting stents) are at significantly increased risk of life-threatening stent clotting complications if these drugs are stopped before 12 months of therapy. For these patients, these drugs should routinely be continued up to the time of cataract surgery.

VIII. GENERAL ANESTHESIA

A small percentage of patients undergoing cataract surgery will not be able to have their operation performed with topical anesthesia or a block. For these patients, GA should be considered.

A. Indications

Not all patients are candidates for regional anesthesia. Children for example would be expected to require GA for cataract surgery to remain motionless. On occasion, GA is necessary for adult patients who are unable to remain motionless because of pre-existing medical conditions (eg, severe Parkinson’s disease, dementia, or claustrophobia) or cannot lie supine because of musculoskeletal, pulmonary, or cardiac disease. For patients with significant medical problems, it would be wise for the ophthalmologist to consult with the anesthesia personnel who will be caring for the patient, in advance of surgery, to determine if the benefits of proceeding with surgery outweigh the potential side effects and risks of GA.

B. Benefits and Risks

The advantages of GA include assurance that patients do not experience any pain and will be immobile. However, there are many disadvantages that include a much higher rate of postoperative nausea, vomiting, drowsiness, confusion, cough, cardiac and respiratory complications, and sore throat. In addition, rare but more serious complications related to GA can occur.

*Dikutip dari Buku Essentials of Cataract Surgery 2nd Ed, halaman 40-41

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