Risk Management

Ocular Regional Anesthesia: Who Should Inject?

 By E. Randy Craven, MD

 Argus, March 1997

Administering anesthesia blocks for ophthalmic surgery used to be the almost exclusive domain of the ophthalmologist; however, more and more anesthesia personnel are now performing blocks, in part because of economic and efficiency pressures. A 1994 survey of more than 557 anesthesiologists indicated that 23% were performing eye blocks.

Eye blocks present a number of possible complications, including globe perforations, optic nerve damage, arterial or venous occlusions, and intraocular hemorrhage. Additionally, anesthesia risks include brainstem anesthesia, respiratory arrest and seizures. Because of these risks, most ophthalmologists do not dispute the necessity of having anesthesia personnel present when blocks are given. The question that arises is: Should anesthesia personnel administer local ocular anesthesia or is it best handled by the ophthalmologist?

Although there may not be one right answer to this question for all situations, it is useful to analyze the potential risks involved when using anesthesia personnel to administer local ocular anesthesia. According to the theory of vicarious liability, physician liability may exist if during surgery the physician “controls” the actions of his or her assistants, including nurses and even other physicians. Generally, the anesthesiologist and Certified Registered Nurse Anesthetist (CRNA) are considered specialists whose authority within that field is superior to that of the ophthalmologist; thus, the ophthalmologist would not control their actions and vicarious liability would not apply. The administration of local ocular anesthesia presents a truly unique situation, however, since an ophthalmologist’s training and experience in this regard may be superior to that of anesthesia personnel. Furthermore, the ophthalmologist is likely to have a better understanding of a particular patient’s eye, such as axial length and history of retinal buckle, and to be in a better position to determine the safest anesthesia technique for the patient in question. Under some circumstances, the ophthalmologist may actually order the type anesthesia he or she prefers. Finally, if an intraoperative complication does occur, such as globe perforation, the ophthalmologist is uniquely qualified to handle this complication.

Given these unique circumstances, it is prudent for the ophthalmologist to use a team approach when deciding to delegate blocks to anesthesia personnel. The ophthalmologist should first assess the anesthesia personnel’s knowledge of ocular anatomy, ability to recognize and prevent complications from anesthesia, and experience performing retrobulbar or peribulbar blocks. Medical malpractice claims adjusters who represent anesthesia personnel indicate that complications are most likely to involve anesthesia personnel who are less experienced giving ocular blocks. On the other hand, anesthesia personnel at eye clinics or surgery centers that routinely perform a large number of blocks per week probably have expertise superior or equal to that of the average ophthalmologist.

The ophthalmologist should be sure to convey to the anesthesia personnel any eye anatomy data specific to a patient undergoing a block. Finally, depending upon the relationship with the anesthesia personnel (e.g., an employed CRNA), the team approach could include special training by the ophthalmologist. In all cases, there should be ongoing dialogue between the ophthalmologist and anesthesia personnel and frequent reassessment of the methods used and results obtained. Should a claim arise in a case where anesthesia personnel administered an ocular block, a team approach would generally be viewed as part of the collaborative nature of medicine and in the best interests of the patient.

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