Systematic Review and Meta-Analysis of Prone Position on Intraocular Pressure in Adults Undergoing Surgery

Diagnosis and Management of Orbital Compartment Syndrome in Burn Patients - a Systematic Review

Orbital compartment syndrome is a poorly understood complication of acute burns. The purpose of this systematic review is to summarize the literature describing orbital compartment syndrome in burn patients to provide greater detail on risk factors and guide management of this morbid condition. A systematic review of the PubMed, Embase, and Cochrane Library databases was performed in June 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using two validated scoring systems. After removing duplicates, 303 unique articles were reviewed and 8 met inclusion criteria. All publications were retrospective. Most studies considered intraocular pressure >30-40mmHg as diagnostic for orbital compartment syndrome. Sixty unique cases of orbital compartment syndrome were reported. Orbital compartment syndrome occurred most frequently within 24 hours post-burn. The mean total body surface area of burn was 58.7%; the mean 24-hour resuscitation volume was 6.01 cc/kg/%total burn surface area; and 86.5% of cases had periorbital burns. Surgical decompression always started with lateral canthotomy. When pressures were not immediately reduced, cantholysis was performed. Study quality per Median Newcastle Ottawa Scores ranged from 38.9% to 94.4% (median 66.7%). A precise threshold for surgical decompression of OCS remains conflicted; however, IOP>30-40mmHg warrants intervention. Burn surgeons/intensivists should be aware of the risk factors for this vision-threatening complication and act appropriately.

[Small tidal volume hyperventilation relieves intraocular and intracranial pressure elevation in prone spinal surgery: a randomized controlled trial]

OBJECTIVE

To investigate the effects of different ventilation strategies on intraocular pressure (IOP) and intracranial pressure in patients undergoing spinal surgery in the prone position under general anesthesia.

METHODS

Seventy-two patients undergoing prone spinal surgery under general anesthesia between November, 2022 and June, 2023 were equally randomized into two groups to receive routine ventilation (with Vt of 8mL/kg, Fr of 12-15/min, and etCO2 maintained at 35-40 mmHg) or small tidal volume hyperventilation (Vt of 6 mL/kg, Fr of18-20/min, and etCO2 maintained at 30-35 mmHg) during the surgery. IOP of both eyes (measured with a handheld tonometer), optic nerve sheath diameter (ONSD; measured at 3 mm behind the eyeball with bedside real-time ultrasound), circulatory and respiratory parameters of the patients were recorded before anesthesia (T0), immediately after anesthesia induction (T1), immediately after prone positioning (T2), at 2 h during operation (T3), immediately after supine positioning after surgery (T4) and 30 min after the operation (T5).

RESULTS

Compared with those at T1, IOP and ONSD in both groups increased significantly at T3 and T4(P < 0.05). IOP was significantly lower in hyperventilation group than in routine ventilation group at T3 and T4(P < 0.05), and ONSD was significantly lower in hyperventilation group at T4(P < 0.05). IOP was positively correlated with the length of operative time (r=0.779, P < 0.001) and inversely with intraoperative etCO2 at T3(r=-0.248, P < 0.001) and T4(r=-0.251, P < 0.001).ONSD was correlated only with operation time (r=0.561, P < 0.05) and not with IOP (r=0.178, P>0.05 at T3; r=0.165, P>0.05 at T4).

CONCLUSION

Small tidal volume hyperventilation can relieve the increase of IOP and ONSD during prone spinal surgery under general anesthesia.

Evaluating the Effects of a General Anesthesia and Prone Position Nursing Checklist and Training Course on Posterior Lumbar Surgery: A Randomized Controlled Trial

BACKGROUND

While general anesthesia in the prone position is one of the most utilized surgical positions, it predisposes to multiple types of complications. Existing studies on this topic are mostly literature reviews or focus on solving one complication, which limits their clinical use.

OBJECTIVE

The aims of the study were to evaluate the effectiveness of a 22-item general anesthesia and prone position nursing checklist and specific training course at preventing complications related to general anesthesia in the prone position.

DESIGN

The study used a randomized controlled trial.

SETTINGS AND PARTICIPANTS

Convenience sampling was used to recruit patients who underwent general anesthesia during posterior lumbar surgery from July 2021 to December 2021 at the Run Run Shaw Hospital, Zhejiang University School of Medicine Hospital.

METHODS

Patients involved in the study were randomly assigned to the control (standard general anesthesia and prone position care) or experimental group (general anesthesia and prone position nursing checklist combined with specific training course in addition to standard general anesthesia and prone position care). Outcomes were pressure injuries, peripheral nerve injuries, ocular complications, and length of stay (LOS). Patient satisfaction, Numeric Pain Rating Scale (NRS) and the Oswestry Disability Scale were also measured.

RESULTS

Compared with the control group, pressure injury, brachial plexus injury, and two ocular findings (foreign body sensation and blurry vision) were significantly less common in the intervention group ( P ≤ 0.01). Participants who received standard general anesthesia and prone position care had lower self-reported satisfaction than those managed with the general anesthesia and prone position nursing checklist plus specific training course ( P = 0.002). The checklist-based intervention also significantly reduced LOS ( P = 0.000) and NRS ( P = 0.000).

CONCLUSIONS

The intervention group had significant fewer general anesthesia in the prone position-related complications, improved satisfaction, reduced LOS, and lower NRS. These findings suggest that a general anesthesia and prone position nursing checklist in addition to a specific training course are beneficial to standardizing prone position nursing care during posterior lumbar surgery.

Guidelines in Practice: Positioning the Patient

Positioning the patient is an important perioperative task; the recently updated AORN "Guideline for positioning the patient" provides perioperative personnel with background information and evidence-based best practices for perioperative patient positioning and focuses on maintaining patient and staff member safety. The revised guideline includes recommendations for placing patients safely in a variety of positions and avoiding positioning injuries, such as postoperative vision loss. This article provides an overview of positioning recommendations for assessing patients' risk for injury, implementing safe positioning practices, placing patients in the Trendelenburg position, and preventing intraocular injuries. It also includes a patient-focused scenario on preventing adverse events associated with the Trendelenburg position that aligns with information discussed in the article. Perioperative nurses should review the guideline in its entirety and implement appropriate recommendations for positioning patients during procedures.

Eye Care Interventions in Critical/Surgical Patients in the Prone Position: Scoping Review

Objectives: This study aimed to map evidence of eye care interventions in managing critical or surgical patients submitted to prone positions. Materials and method: This scoping review was prepared according to the Joanna Briggs Institute’s methodology, following the PRISMA-ScR criteria. A search was conducted from July to August 2020 in the SCOPUS, Web of Science, Science Direct, PubMed Central, CINAHL, and COCHRANE databases. The following research question was delimited: “What are the strategies and interventions used for eye care in the management of critical patients or surgical patients submitted to the prone position?” The sample consisted of 24 studies after applying the inclusion and exclusion criteria. Results: Eye care interventions in managing critical/surgical patients submitted to the prone position were eye examination, use of lubricants/specific ophthalmic solution, reverse Trendelenburg positioning, and protection with adhesive tape. Conclusions: This review allowed the understanding of eye care for critical/surgical patients in a prone position. Among the care presented, a large part is related to nursing since it is closer to patient care. The findings emphasize the need to implement patient safety policies with eye care as a priority.

Anisocoria in an intubated patient with COVID-19

The effects of COVID-19 on the eye are still widely unknown. We describe a case of a patient who was intubated and proned in the intensive care unit (ICU) for COVID-19 and developed unilateral anisocoria. CT venogram excluded a cavernous sinus thrombosis. MRI of the head showed microhaemorrhages in the midbrain where the pupil reflex nuclei are located. After the patient was stepped down from ICU, intraocular pressure (IOP) was found to be raised in that eye. A diagnosis of subacute closed angle glaucoma was made. It is important for clinicians to rule out thrombotic causes in patients who develop acute anisocoria. It is also crucial to measure IOP in patients who develop ophthalmic pathology and have been proned for extended periods.

A Simple Method for Eye Protection During Prone Positioning for Craniofacial Surgery

Surgery in the prone position risks vision loss due to a number of factors. Craniofacial surgery poses an even greater risk due to the anatomical and physiological makeup of these patients. Here, we describe a novel method of providing protection from direct pressure on the globe during prone positioning for craniofacial procedures and our protocol for improving safety and reducing the risk of postoperative vision loss.

Comparison of intraocular pressure during laparoscopic totally extraperitoneal (TEP) versus transabdominal preperitoneal (TAPP) inguinal hernia repair

BACKGROUND

Laparoscopic totally extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are standard laparoscopic procedures for inguinal hernia repair. Some evidence has shown that pneumoperitoneum can cause an increase in intraocular pressure (IOP) during surgery. This study aimed to compare intraoperative IOP following extraperitoneal CO₂ insufflation with the TEP approach and intraperitoneal CO₂ insufflation with the TAPP approach.

METHODS

This study is a prospective cohort study. Patients who had inguinal hernias suitable for laparoscopic inguinal hernia repair were assigned to undergo the TEP or TAPP approach. We measured preoperative, intraoperative, and postoperative IOP. The IOP of the TEP and TAPP groups was evaluated using a t test. The relations between peak inspiratory pressure (PIP), mean arterial pressure (MAP), and end-tidal CO₂ (EtCO₂) were estimated using ANOVA. Univariate and multivariate analyses were performed to determine the factors associated with IOP.

RESULTS

There were 50 patients in this study (TEP group n = 25, TAPP group n = 25). The change in intraoperative IOP from the preoperative measurement to the measurement after CO₂ insufflation was not statistically significant in either the TEP or TAPP group (p value = 0.357). There was no significant difference in intraoperative IOP change between the TEP and TAPP groups. Intraoperative MAP and PIP were related to IOP, but intraoperative EtCO2 was not.

CONCLUSIONS

There was no significant intraoperative IOP change during laparoscopic inguinal hernia repair. Both the TEP and TAPP techniques can be performed safely without increasing intraoperative IOP.

Ocular Complications in the Prone Position in the Critical Care Setting: The COVID-19 Pandemic

PURPOSE

Ocular complications are common in the critical care setting but are frequently missed due to the focus on life-saving organ support. The SARS-CoV-2 (COVID-19) pandemic has led to a surge in critical care capacity and prone positioning practices which may increase the risk of ocular complications. This article aims to review all ocular complications associated with prone positioning, with a focus on challenges posed by COVID-19.

MATERIALS AND METHODS

A literature review using keywords of "intensive care", "critical care", "eye care", "ocular disorders", "ophthalmic complications," "coronavirus", "COVID-19," "prone" and "proning" was performed using the electronic databases of PUBMED, EMBASE and CINAHL.

RESULTS

The effects of prone positioning on improving respiratory outcomes in critically unwell patients are well established; however, there is a lack of literature regarding the effects of prone positioning on ocular complications in the critical care setting. Sight-threatening ophthalmic disorders potentiated by proning include ocular surface disease, acute angle closure, ischemic optic neuropathy, orbital compartment syndrome and vascular occlusions.

CONCLUSIONS

COVID-19 patients may be more susceptible to ocular complications with increased proning practices and increasing demand on critical care staff. This review outlines these ocular complications with a focus on preventative and treatment measures to avoid devastating visual outcomes for the patient.

Clinical Anatomy of the Extradural Neural Axis Compartment: A Literature Review

OBJECTIVE

The extradural neural axis compartment (EDNAC) is an adipovenous zone located between the meningeal and endosteal layers of the dura and has been minimally investigated. It runs along the neuraxis from the orbits down to the coccyx and contains fat, valveless veins, arteries, and nerves. In the present review, we have outlined the current knowledge regarding the structural and functional significance of the EDNAC.

METHODS

We performed a narrative review of the reported EDNAC data.

RESULTS

The EDNAC can be organized into 4 regional enlargements along its length: the orbital, lateral sellar, clival, and spinal segments, with a lateral sellar orbital junction linking the orbital and lateral sellar segments. The orbital EDNAC facilitates the movement of the eyeball and elsewhere allows limited motility for the meningeal dura. The major nerves and vessels are cushioned and supported by the EDNAC. Increased intra-abdominal pressure will also be conveyed along the spinal EDNAC, causing increased venous pressure in the spine and cranium. From a pathological perspective, the EDNAC functions as a low-resistance, extradural passageway that might facilitate tumor encroachment and expansion.

CONCLUSIONS

Clinicians should be aware of the extent and significance of the EDNAC, which could affect skull base and spine surgery, and have an understanding of the tumor spread pathways and growth patterns. Comparatively little research has focused on the EDNAC since its initial description. Therefore, future investigations are required to provide more information on this underappreciated component of neuraxial anatomy.