FEATURE ›› INTRAOPERATIVE COMPLICATIONS

Managing INTRAOPERATIVE COMPLICATIONS

They’re inevitable but preparation and prevention can help you minimize their impact

BY VIRGINIA PICKLES, CONTRIBUTING EDITOR

You may have heard the old chestnut: The only surgeon who doesn’t have complications is the one who doesn’t operate. According to three top retina surgeons, this is absolutely true. Rather than think about what you would do if you encounter a complication during one of your surgical cases, you need to prepare for when one occurs.

By their very nature, intraoperative complications are unexpected, but you can take steps to minimize their impact. In this article, retina specialists Carl C. Awh, Nashville, Tenn., Sophie J. Bakri, Rochester, Minn., and Seenu M. Hariprasad, Chicago, share some of their strategies for preventing complications, and how they manage them when they do occur.

PREVENTIVE MEASURES

›› Emphasize the “Informed” in Informed Consent

The first step toward managing complications takes place long before you enter the operating room (OR) or the surgery suite, Dr. Awh says. “It’s really important that doctors get comfortable with the informed consent and making sure patients understand that surgery is an imperfect science,” he says. “Even a straightforward surgery can have a bad outcome, and our obligation as surgeons is to make sure patients understand the risks so they can balance those risks with the potential benefits.”

Dr. Hariprasad recommends making informed consent interactive. “Informed consent should be a process, not just a signature on a piece of paper,” he says. “Involve patients in discussions about their surgeries, so they feel they’re part of the team. They should be able to verbalize back to you what you believe they should understand.”

Dr. Hariprasad also cautions against overloading a patient with every possible surgical outcome or scenario. “Don’t dwell on unlikely complications,” he says. “When I discuss complications with a patient, I categorize them as: 1) seen with some frequency; 2) highly unusual; and 3) theoretical. For example, the odds of having a bleed after a surgery may be in the low double digits, whereas, the rate of dying may be 1 in 500,000. Patients don’t know that.”

›› Know Your Patient

When assessing a patient’s risk factors, a surgeon must consider all aspects of the patient’s history. “Any number of factors can lead to potential complications,” Dr. Bakri says. “Blood thinners, high myopia, hypertension, diabetes, even herbal remedies can affect your outcomes. It’s important to know about them and anticipate their impact on your surgery.”

›› Plan Ahead

Similar to how athletes prepare for competition by visualizing the course of a race, surgeons should also consider how to approach each case. “Well in advance of the surgery day, review your cases and think about how you’re going to attack each one,” Dr. Awh says. “Rehearse not just the perfect case but also what you would do if disaster scenario A, B or C unfolds. Then, on the day of surgery, you’re reviewing your plan, not trying to create it.”

Dr. Awh also recommends speaking with a mentor or colleague about your plan. “For about a year after I finished my fellowship, one of my co-fellows and I routinely discussed the cases we had coming up that week,” he recalls. “Even when you feel confident you know how to do something, it’s reassuring when someone else says, ‘Yes, that’s exactly how I would do it.’ As the months go by, you’ll start to realize you don’t need those conversations as much.”

Dr. Bakri offers the same advice and adds, “As much as possible, adhere to what you’ve been trained to do. Don’t come out of fellowship and try to outsmart everyone who taught you, because chances are your teachers and mentors have already tried all of these different approaches, are aware of the complications, and have refined the techniques to make them reproducible and to minimize complications.”

Also, if you’re new in a practice, become acclimated to your OR. “If you have an opportunity to go into the OR with a senior partner, make the time to do so,” Dr. Awh says. “Watch the senior partners operate and learn how they function in the OR. They likely have developed tricks and routines that enable them to work most efficiently and safely in the OR.”

›› Know Your Team

“As a new surgeon in a new OR with new staff, take 5 minutes to talk to the nurses about your methods and preferences,” Dr. Hariprasad says. “During a case is not the time to send a nurse to the other side of the hospital for forceps she’s never heard of. All of those things — instrument preferences, the possibility you’ll use a laser probe or need silicone oil — should be discussed before you begin a case. Nurses appreciate that discussion, and having a team that’s prepared is another way to manage complications.”

›› Know Your Equipment

“It’s important for surgeons to familiarize themselves with the equipment at a new hospital or surgery center,” Dr. Awh says. “If something malfunctions during a case, it’s not unusual for the surgeon to be the one who discovers the problem. Even staff members who have worked with the equipment for years sometimes only know how to operate it when it’s working properly. They may not know how to troubleshoot. The more you can understand the equipment and what can go wrong with it, the better you’ll be able to manage equipment-related complications. If the eye suddenly goes soft, for example, you should be able to quickly check off items on a mental checklist to address the hypotony.”

›› Standardize Your Procedures

Try to standardize everything you do in the OR, Dr. Bakri advises. “Have a method for doing things and try to adhere to that method as much as possible,” she says. “Don’t try to reinvent the wheel for every case, and don’t skip steps. Make every step as routine as possible. Stick to what you know works.”

›› Choose Your First Cases Wisely

“Try to choose easy cases initially for your first few solo surgeries,” Dr. Bakri says. “As you move on to more complex cases, seek the advice of an experienced colleague or mentor, someone you can call if you run into trouble.”

PREOPERATIVE PREPARATIONS

›› Call a Time Out

Most institutions require a time out in the OR, and Dr. Hariprasad believes this is an important step, especially for new surgeons. “I believe the time out is critical,” he says. “Under the drape, patients look the same, eyes look the same. During the time out, the entire team stops what they’re doing. You say the name of the patient. You read the consent form. You go over what procedure is being done. Everyone in the room agrees, and the case goes forward. A time out also helps create a zen state of mind, so that everyone has the appropriate level of seriousness, because we’re about to perform surgery.”

›› Get in the Zone

Being mentally prepared for surgery day is as important as your surgical training, according to Dr. Hariprasad. “The concentration you should have when you’re in a patient’s eye is exquisite, almost spiritual,” he says. “That patient trusts you. Always respect that. There can be no distractions, no text messages coming in on your phone, no one making jokes.”

How does Dr. Hariprasad get in the zone? “For me, it starts during the scrubbing process,” he says. “When I sit in the chair and pull in the scope, my concentration is like an eagle. I’m ready to go. The senses come together with razor focus. It’s an exquisite experience that only a fellow surgeon can understand.”

›› Set Your Own Pace

Efficiency in the OR is important, but efficiency doesn’t necessarily equal speed, according to Dr. Awh. “In terms of avoiding complications, new surgeons shouldn’t worry about speed in the OR, despite what they perceive staff may be thinking,” he says. “Operating room staff work with many different surgeons, but they often don’t have a good understanding of what is happening inside the eye. The goal should never be to finish a case as quickly as you can but to achieve the best possible result, because that’s what matters to the patient.”

Efficiency improves with experience, and speed has less to do with manual dexterity than it does with the thought processes during surgery. “The goal is to continually become more efficient, to decide what the next step should be and to perform that step without hesitation,” Dr. Awh says. “What mainly makes us quicker as surgeons is that, with experience, our decision-making becomes more efficient. During fellowship, most of us performed our surgeries with a mentor guiding us through the steps. When you suddenly become the person who makes all of the decisions and is also performing the surgery, it’s far more challenging. Therefore, it’s natural that you need more time, because you have to consider all of the possibilities, make your decision and then execute. So don’t be anxious about not being as fast as you might have been during fellowship. The speed will come. Concentrate on ensuruing a good outcome.”

WHEN THE INEVITABLE HAPPENS

›› Stay Calm and Assess Quickly

“When something unexpected happens during a surgery, be calm and react quickly,” Dr. Bakri says. “Try to think logically about what needs to be done to save the eye. In other words, if things are good, don’t spend time trying to make them perfect. Accept that they’re good, that the eye is safe, and that you’ll do what you need to do and close the eye.”

Dr. Hariprasad advises, “When a complication occurs, keep your cool, stop and think. Under very few circumstances will moving faster improve an outcome. Think about how you can fix the problem, and calmly instruct the nurse, ‘Prepare the gas for me. Get me a laser probe. I need perfluorocarbon liquid.’ Ask for items you’ll need in the order in which you’ll use them.”

One other point Dr. Hariprasad stresses is that, in most cases, patients can hear what’s being said in the OR, which is another reason to stay calm and avoid verbalizing your dismay. “About 95% of my surgeries are performed under local anesthesia, and patients can hear everything,” he says. “Imagine you’re a patient under the drape while a surgeon is operating inside your eye and someone blurts out, “Oh my God!’ It has to be a terrifying experience. Always put yourself in the patient’s shoes.”

Dr. Awh adds this reassurance: “Most surgical complications are manageable, and in most cases, the patient will never know that their surgery wasn’t a textbook case, because the outcome won’t suffer.”

›› Be Honest

Your next most difficult task after managing a complication may be explaining the situation to a patient and his family. “If, at the end of a case, I feel the outcome won’t be what I told the patient was likely before the case, the first thing I do is speak with the patient’s family,” he says. “I explain what went well with the case and what we achieved. Then, I explain what we were unable to achieve and, if possible, why. It’s very important to be direct and honest with patients and their families.”

Dr. Bakri agrees. “The best policy is honesty,” she says. “Be open with the patient and the family. Tell them exactly what happened, what you did to prevent it, what you expect the outcome will be and if another surgery may be required. It may be helpful to remind the patient that you discussed potential complications before the surgery and, although they rarely happen, unfortunately in this case, an unexpected complication did occur.”

Except in extreme situations, Dr. Hariprasad doesn’t discuss a complication until the 1-day post-op visit. “The patient has just had eye surgery, he has a patch on his eye, and he’s groggy from anesthesia,” he explains. “That’s not the best time to have a discussion about a complication. What’s more, although a surgery didn’t go the way I expected, the outcome may not be as poor as I thought it would be. Sometimes, the patient does very well. After I examine the eye on the first day post-op, if necessary, I then explain that the surgery didn’t go as expected and what our next steps will be.”

›› Choose Your Words Carefully

You can be honest about what happened during a surgery without assigning or accepting malpractice culpability. “Patients need to understand that cases sometimes don’t go the way one wants them to,” Dr. Awh says. “It’s very different to say, ‘The eye began bleeding in a way that I could not control,’ than to say, ‘I caused uncontrollable bleeding.’

›› Offer Hope

“Ideally — and this is almost always true — you can give patients hope that with more surgery, the eye should improve,” Dr. Awh says. “Always reassure patients that you’re on their side, and you’re truly disappointed for the patient that the surgery happened to be more difficult than expected, but you’re there to fight the fight with him.”

›› Be Humble

“I think it’s a natural tendency, especially for young surgeons, to not want to reveal perceived flaws to staff or patients,” Dr. Awh says. “You’re the new person, and you want to do a great job, but it’s not realistic to expect perfection. I think patients and staff appreciate when the doctor shows humility.”

Dr. Hariprasad adds, “Your goal is to do the best you can to fix the eye, and not every eye is meant to be fixed. Being a retina surgeon can be very humbling, because you may do everything perfectly, and the retina doesn’t stay attached or the macular hole doesn’t close. We’re all humbled when we see that. Don’t throw in the towel. Don’t beat yourself up. There are things to learn.”

›› Seek Help

After a complication has occurred, don’t be afraid or reluctant to ask for help. “Don’t try to hide your imperfect outcome from your colleagues,” Dr. Awh says. “That’s when you should go to people with experience and ask for advice and help. Sometimes, it’s best to let another surgeon perform the re-operation, even if it’s one you could do. Sometimes the emotion can be overwhelming for a younger surgeon. Having another surgeon in the OR with you or having someone perform the surgery instead of you may be the wisest decision.”

›› Notify Risk Management

After consulting with a senior surgeon, you may decide you need to involve your institution’s risk management specialist to determine your level of exposure and the steps you should take. “You should have a low threshold to notify risk management when complications arise that pose a medicolegal risk,” Dr. Hariprasad says. “The risk management team’s job is to protect us and navigate these situations. They will advise you appropriately.”

›› Breathe

“We’re all imperfect, and cases aren’t always going to go perfectly,” Dr. Awh says. “Complications are inevitable, but with experience, you’ll be able to recognize which ones will make a significant difference in outcome for the patient, compared with what the patient should have realistically expected.

“When you’re young, it’s not uncommon to blame yourself for imperfect outcomes,” Dr. Awh says. “By the time you’ve completed a few thousand cases, you’ll understand that no one can bat a thousand. You’re still disappointed for the patient and for yourself when the outcome is less than ideal, but you learn to accept that it’s just part of being a surgeon.” NRP