10/1/2012. Recognizing Causes, Minimizing Risk Susan Clouser RN MSN CRNO. Independent TASS/Endophthalmitis Consultant (Eye Consult LLC) Alcon Contract

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1 Recognizing Causes, Minimizing Risk Susan Clouser RN MSN CRNO Independent TASS/Endophthalmitis Consultant (Eye Consult LLC) Alcon Contract Toxic Anterior Segment Syndrome Sterile endophthalmitis Inflammation in the anterior chamber following cataract surgery that is NOT an infection. 1

2 TASS has symptoms similar to endophthalmitis Increased cell and flare Hypopyon Decreased visual acuity Time frame is different TASS shows up in 4-24 hours Endophthalmitis takes hours Endophthalmitis: Antibiotics TASS: Steroids Mild Moderate Severe 2

3 TASS is usually multifactorial When the inflammation is more than expected. Patient had surgery so some inflammation is expected. More inflammation expected with a dense nucleus and/or other ocular problems 1= normal postop inflammation 10= this looks like TASS 1+9= = =10 3

4 Inadequate/inappropriate instrument cleaning and flushing Touching things that go inside the eye Irrigating solution and Medication issues Endotoxin Particulates Inadequate manual cleaning Insufficient flushing Inappropriate use of enzymatic cleaners, detergents, stain removers and lubricants Phaco tip/sleeve I&A tip/sleeve Cannulas IOL IOL cartridge 4

5 Preserved medications Irrigating solutions with additives Irrigating solutions contaminated on the field Possibly denatured OVD Epi-Shugarcaine Sterilizer reservoirs Ultrasonic cleaners Reused flushing tubing Lint from any and everything Cloth towels Paper towels Gowns Wrappers Back table cover 5

6 Doctor reports TASS Facility investigates Several changes made at once TASS goes away (but what was it?) or TASS comes back Initial changes reversed due to cost/time New changes instituted If initial changes kept in place and more added the last thing changed prior to cessation of TASS is concluded to be the cause. Thorough and appropriate instrument cleaning Don t touch things going inside the eye Don t contaminate irrigating solution Eliminate endotoxin Closely monitor medications and OVD Minimize particulates 6

7 Manual cleaning of instruments Manufacturer s directions for use Brush Rinse Flushing of items with a lumen Manual Syringe and adapter Discard the water Air Blowout Automated Account for resistance Account for simultaneous lumen flushing Water in the bottle 7

8 Among the young engineers we interview we find few who have received thorough training in engineering fundamentals or principles; but most have absorbed quantities of facts...much easier to learn than principles but of little use without application of principles. Once a principle has been acquired it becomes a part of one and is never lost. It can be applied to novel problems and does not become obsolete... Don t touch anything that is going inside the eye Virgin BSS If it is going inside the eye: DON T TOUCH IT!!!!! 8

9 BSS given to the surgeon to use inside the eye should not have any contamination. Don t reach in it Don t soak in it Don t swish in it. Nothing diluted in it Discard disposables used in cleaning and flushing Dry out reusable equipment and wipe with alcohol StatIM cassettes Flashguard pans Ultrasonic cleaner Anything intraocular must be preservative free Shugarcaine/epi-Shugarcaine Additives to BSS 500 BSS Plus (Part 1 + Part 2) 9

10 Must be removed from instruments during cleaning Must be properly shipped and stored How hot is too hot? Minimize what is on back table Minimize moving it around Rinse instruments as needed TASS can be mild, moderate or severe TASS can come from a variety of sources There is usually more than one etiology associated with an outbreak 10

11 To minimize risk Learning and applying the big principles Monitoring medications Eliminating endotoxin Minimizing particulates QUESTIONS??? 11