Ophthalmic Lasers, Refractive Procedures and Surgical Techniques. Nimesh Patel Coursemaster Room 2157 Office

Transcription

1 Ophthalmic Lasers, Refractive Procedures and Surgical Techniques Nimesh Patel Coursemaster Room 2157 Office

2 Recommended text

3 Grading Class 2 tests, and one final. Each exam is worth 30% of total grade. Refer to the class syllabus for the grading scale. Attendance/Participation 10% of total grade. Lab A missed lab session will constitute a failure in the lab portion of the course. If you are late to lab, ½ grade drop for each time. You are required as part of the lab to observe a refractive surgery procedure during this semester.

4 Ophthalmic Lasers Lab Monday and Wednesday N Patel, and K Schulle Tuesday and Thursday K Lambreghts Wednesday 18 th Both groups A and B will meet. Monday 23 rd lab Both groups A and B will meet.

5 Injections References: 1. Taylor s Clinical Nursing Skills 2. Clinical Medicine in Optometric Practice

6 Injections What you can do in regards to treatment is regulated by state law. It is important to know what your state requires for licensure (NBEO, state exam, etc). In Texas injectables are not in the state law. However, surrounding states including Louisiana, Oklahoma, and New Mexico they are. It is possible/likely that the state you practice in requires you to know these skills. Optometry rules and laws by state

7 Injections Enteral medications that are delivered through the gastrointestinal system. Oral, sublingual, rectal Parenteral medications that are not delivered through the gastrointestinal system. Injections, shunts, patches

8 Injections WHY? Used for diagnosis and treatment of many ocular conditions Intravenous Subcutaneous Intramuscular Intradermal Intraocular / Intravitreal Intralesional

9 Injections Non-ocular Intravenous 0-5 min Intramuscular min Subcutaneous 30 min Intradermal min Ocular Intralesional Subconjunctival Subtenons Intraocular Retrobulbar

10 Injections Absorption Process by which a drug is transferred from site of administration into the bloodstream. Hydro phillic vs phobic, ph, vasculatity Distribution Does the drug get to the site that you need it. Blood-brain barrier Pregnancy Metabolism How fast is the drug deactivated, or activated Interactions with other drugs (Liver) Excretion Need to consider the health of the kidneys in many cases

11 Blood draws Regulatory standards that apply to labs that collect human specimens for testing. Clinical Laboratory Improvement Amendments (CLIA).

12 Basic Principles Safety Never forget rules!

13 Universal precautions Protect yourself and your patient. Treat all instances as you would in the presence of an infectious disease. Always wash your hands and wear gloves Hand washing Remove any jewelry, bracelets, watches, etc Turn on the water first, make sure it is not splashing all over the place Wet hands, and use ~1 teaspoon of liquid soap Wash between the fingers and ~1 inch above the area that needs to be clean. (approximately sec) Clean your fingernails. Rinse with your fingers pointing downward If you are regularly using gloves, use a oil-free lotion on your hands.

14 Rights of Medication Administration Right medication is given to Right patient in the Right dosage, through the Right route at the Right time for the Right reason based on the Right assessment data using the Right documentation and monitoring for the Right response by the patient. There is also a Right to education and Right to refuse THE NINE + TWO RIGHTS OF MEDICATION ADMINISTRATION

15 Rights of Administration Always check Drug allergies Drug interactions Dosage and appropriateness of the medication The route at which the drug is to be administered Patients should be educated on the rationale for the injection administered (informed consent). In the patient s chart, should document Consent Drug Administered route, dose, and location Complications

16 Sharps If ever in doubt, discard the needle in the sharps container and start again. If you have to recap a needle, use a one handed scoop technique. Once you have administered an injection: NEVER RECAP A NEEDLE! Dispose of the needle in the sharps container

17 One handed scoop technique

18 CDC NEEDLESTICKS! In the US, approximately 800,000 accidental needlesticks occur annually.

19 OSHA Occupational Safety and Health Act (1970), legal standards to ensure safe and healthful working conditions for men and women. If working with biohazards, offer vaccinations (Hep A&B), at the employer s expense Worker training in appropriate engineering controls and work practices Post-exposure evaluation and follow-up, including post-exposure prophylaxis when appropriate.

20 OSHA Employers shall select and require employees to use appropriate hand protection when employee s hands are exposed to hazards such as those from skin absorption of harmful substances; severe cuts or lacerations; severe abrasions; punctures; chemical burns; and harmful temperature extremes Employers shall base the selection of the appropriate hand protection on an evaluation of the performance characteristics of the hand protection relative to the task(s) to be performed, conditions present, duration of use, and the hazards and potential hazards identified Wear gloves!

21 OSHA A written exposure control plan designed to eliminate or minimize worker exposure to bloodborne pathogens Compliance with universal precautions Engineering controls and work practices to eliminate or minimize worker exposure Personal protective equipment Prohibition of bending, recapping, or removing contaminated needles Prohibition of shearing or breaking contaminated needles

22 Basic Principles - Tools

23 Syringe 3 cc syringe without needle Knob Plunger Barrel Tip Syringe you select depends on the procedure and amount of drug delivered

24 Syringe SLIP LOCK LUER LOCK

25 Needles BEVEL HUB SHAFT Key point/fact: The needle dives away from the bevel.

26 Needles BEVEL HUB SHAFT Other factors: Route of administration IM needs longer needle Viscosity of drug lower gauge for more viscous Individual differences (technique and patient)

27 Needles 22G 23G Gauge Larger gauge needles are thinner You want to use a needle appropriate for the drug you are delivering. Smaller gauge needles might be needed for thicker solutions. For most eyecare needs a 23 gauge or larger is appropriate. The color of the hub will provide you information on the gauge of the needle.

28 Needles Pull in this direction When removing the cap, do not 1. Wiggle the cap 2. Struggle with the cap 3. Hold the hub of the needle (sterile) Hold here When removing the cap, 1. You might want to gently push the needle on (if slip lock) 2. Hold the cap closer to the top (away from the hub region) 3. Using a parallel motion, remove the cap in one pull

29 Medications

30 Vials Multiuse. If possible, retain same patient to the vail if possible.

31 Vials Multiuse. If possible, retain same patient to the vail if possible. Drugs in suspension, such as Kenalog, when sitting around will separate, and need to be mixed

32 Vials In some instances, you will have to mix the drug prior to use. With botox, need to add 1-8 cc of sterile saline to the vial prior to use. (botox is in a vacuum)

33 Act-O-Vial

34 Vials Clean the rubber stopper with an anti-microbial wipe (alcohol prep). LET IT AIR DRY PRIOR TO PROCEEDING.

35 Vials Clean the rubber stopper with an anti-microbial wipe (alcohol prep). LET IT AIR DRY PRIOR TO PROCEEDING. WET DRY

36 Taylor s clinical nursing skills. Vails 1. Select the appropriate syringe and needle. 2. Pull an equal amount of air into the syringe as the drug needed. 3. Insert the needle into the center of the rubber stopper. 4. While the needle tip is in air inject the air you pulled up. 5. Invert the vail and syringe. 6. Position the needle so that it is covered by medication. 7. Draw up the amount of drug that will be injected. 8. Change the needle if needed, or using one handed scoop recap if needed.

37 Ampule WHAT IS THE DIFFERENCE BETWEEN THESE TWO AMPULES?

38 Ampule Scored Ampules are scored, so you can snap them open. Epinephrine, Sodium Fluorescein, Indocyanine green, are examples that are sold in ampules. Be careful when snapping, use a gauze if available, and point away from you.

39 Ampule Taylor s clinical nursing skills.

40 Ampule ALWAYS USE A FILTERED NEEDLE TO WITHDRAW THE MEDICATION TO PREVENT PULLING UP GLASS PARTICULATE Taylor s clinical nursing skills.

41 Injection Techniques Taylor s clinical nursing skills.

42 Intradermal Drug is delivered to the dermis of the skin Has the longest absorption time Typically used for TB sensitivity Tine test Not used anymore Mendel-Mantoux Allergy testing Local anesthesia Vaccine

43 Intradermal Commonly administered to the forearm or the back. Use a tuberculin syringe (1cc) with a ¼ or ½ 27G needle.

44 Intradermal Clean the area to be injected with anti-microbial, and allow to dry. Make the skin in the region taut. Hold the syringe at a 5-15 degree angle, with the bevel up (facing you). Insert the needle ~1/8 to 1/4 in. You might be able to see the bevel through the skin. Inject the drug. Maximum of 0.5ml You should see a small wheal or blister appear. Remove the needle quickly **Do not rub the area**

45 Intradermal Taylor s clinical nursing skills.

46 Injection Techniques Taylor s clinical nursing skills.

47 Subcutaneous Drug delivered in the adipose layer under the dermis of the skin. Scant vasculature allows for slow, but steady absorption of the drug. Should be administered to a region that is not inflamed, does not have a scar, is not bruised, has not been used recently, not close to a bony protuberance. Typically used for Insulin Heparin

48 Subcutaneous Typically use a tuberculin syringe with 27G 1/2 needle. Select the region you would like to inject, clean area let air dry. Absorption fastest to slowest Abdomen Arms Thighs Gluteal Taylor s clinical nursing skills.

49 Subcutaneous Usually limit medication delivered to 1ml For insulin 28-30G needle is typically used 5/16 to 1/2

50 Subcutaneous Bunch up the tissue in the area gently. Insert the needle between 45 and 90 degrees Bevel?? Facing you Release the skin, but make sure the needle follows the skin Aspirate?? Current standards do not require you to aspirate. In fact if you aspirate too hard, you can get a bruise if treating the patient with heparin. Inject the medication slowly Remove the needle and dispose in sharps. Place gauze over the region, do not rub the region as it can alter the rate of drug delivery.

51 Taylor s clinical nursing skills. AVOID POINTING NEEDLE TOWARDS YOU!

52 Subcutaneous Injection Taylor s clinical nursing skills.

53 Injection Techniques Taylor s clinical nursing skills.

54 Intramuscular Drug delivered into the muscle layer. Muscles have increased vasculature, and so absorption of the drug is fast. Antibiotics, Vaccines, Steroids can all be administered by IM. The volume of drug delivered is limited to between 1-4 ml.

55 Intramuscular Taylor s clinical nursing skills. Sites Ventrogluteal Vastus Lateralis Deltoid

56 Thieme Atlas of Anatomy

57 IM - Deltoid

58 IM - Deltoid Thieme Atlas of Anatomy

59 Intramuscular Site Vastus lateralis Deltoid (child) Deltoid (adult) Ventrogluteal Needle length 5/8 to 1 inch 5/8 to 1 ¼ inch 5/8 to 1 ½ inch 1 ½ inch These are general guidelines. You need to alter the procedure according to your patient and their needs. Remember. Avoid bone, avoid nerves and avoid vasculature. The bevel needs to be in muscle.

60 Intramuscular Clean the region of interest, and let air dry. Needle angle should be between 72 and 90 degrees Bevel position does not matter Stabilize the skin Use the z-track technique when injecting drugs that can cause irritation (perform needle exchange) Use dart-like motion to insert the needle Aspirate?? Maybe with large molecule drugs such as penicillin Inject the medication at 10 seconds per ml Apply gentle pressure following the procedure, avoid rubbing

61 Injection Techniques

62 Z-track technique Taylor s clinical nursing skills.

63 Intramuscular Injection Taylor s clinical nursing skills.

64 Air Lock Technique To ensure all drug is delivered and To prevent irritation of medications in superficial layers ~ ml of air follows the medication that is delivered. Yes it means pulling air into the syringe. However, this technique is not frequently used anymore. Use the Z-track technique instead. There are exceptions, e.g. Lovenox.

65 Intravenous The cephalic, accessory cephalic, metacarpal and basilic veins are appropriate. Always start distal Use the larger veins for hyperosmotics Used for larger volumes, and have rapid onset. Remember bevel faces you (up)

66 Intravenous Apply tourniquet 3-4 inches above the site. Open and close the fist. If veins cannot be seen Massage the arm and gently tap over the vein Place a warm moist compress over the region of interest Clean the region with anti-microbial and let air dry Stabilize the region without touching the cleaned area Enter at an angle of degrees with bevel up (facing you), till you see blood return. Remove the tourniquet Next step depends on the procedure/purpose Maintain needle/catheter

67 IV

68 Injections IM, SC and IV

69 Antibiotics When topicals are not working or appropriate When a patient has poor compliance with a pill Hospital bound Child When a patient is not responsive to traditional treatment

70 Antibiotics Lacerations Preseptal Hyperacute conjunctivitis Orbital cellulitis Dacryocystitis Blow-out Ruptured globe Intraocular foreign body

71 Adverse Reactions Hypersensitivity Rashes Fever Steven-Johnson s Syndrome Anaphylaxis

72 Ceftriaxone - Rocephin Antibiotic Third generation cephalosporin Broad Spectrum Soft tissue infection Pediatric preseptal cellulitis mg/kg (max 2g) IM or IV

73 Anti-Inflammatory Agents For severe and chronic allergic and inflammatory conditions Usually best to try orals first

74 Anti-inflammatory Zoster Iridocyclitis Chorioretinitis Optic neuritis Allergic conjunctivitis Allergic marginal corneal ulcers Numerous adverse reactions adrenal suppression, peptic ulcers, immune suppression

75 Steroids Hydrocortisone Methylprednisolone Triamcinolone Dexamethasone Betamethasone

76 Acute angle closure Mannitol Hyperosmotic 1-2 g/kg (15-20% sol) IV over 45 minute period IOP reduction within minutes Contraindications Hypotension Renal disease Congestive heart failure Side effects Mental confusion Subarachnoid and subdural hematomas Diuresis Headaches Heart failure

77 Acute angle closure Acetazolamide Carbonic anhydrase inhibitor mg PO q4hrs or bid (not sequel) 500 mg IV slow push with mg q4hrs Contraindications Hypersensitivity to sulfa medications Kidney or liver disease Severe COPD

78 Diagnostic agents Sodium Fluorescein Indocyanine green Tensilon

79 Fluorescein Angiography Why Vascular compromise of the retina, choroid and optic nerve Sodium Fluorescein is a low molecular weight vegetable dye. 80% of it binds to albumin. Pharmacologically inert (very important) Absorption at nm Emission at nm

80 Fluorescein Angiography IV started with ~23G Administer 5cc of 10% NaFl or equivalent at the rate of 1cc per second. The entire bolus should be in, in less than 10 seconds. Start the video recording or start taking images to capture the choroidal flush, arterial and venous phases. After the venous phase, wait ~10 min to get the late phase images.

81 Fluorescein Angiography Powdered NaFl or 15ml of 10% can be ingested. Need to have patient remove dentures Ask the patient to fast for 8hrs prior Want to add taste to it, so usually served with citrus drink and ice.

82 Fluorescein Angiography Complications. 4.82% of patients suffer an adverse effect 2.24% - nausea 1.78% - vomiting 0.34% - urtricaria or puritus Very rare are cases of anaphylactic shock 0.05% Higher rate with 25% than 10% NaFl Death 1:50000 (0.002%) to 1: ( %) Allergic and anaphylactic reaction Syncope ( %) Myocardial infarction 1:4400 (0.02%) to 1:37000 (0.002%).

83 Fluorescein Angiography How can you test if your patient has an allergy to NaFl? Intradermal injection of 0.5ml and wait for minutes.

84 Fluorescein Contraindications Previous reaction Moderate to sever asthma with poor control Recent history of CVA, MI or unstable angina Pregnancy and lactating Radical mastectomy with impaired lymphatic drainage.

85 Fluorescein pt education Informed consent Misconceptions Dye injected in eye Undergoing therapeutic procedure X-ray technique Skin and urine color changes Possible allergic reaction and nausea Interference with medical laboratory tests

86 Informed consent.

87 Exam Form

88 Tensilon - Reminder Myasthenia gravis is an autoimmune disease targeting the nicotinic receptors. Patients present to the office with muscle weakness and ptosis.

89 Tensilon Certain drugs in the aminoglycosides family can inhibit calcium uptake and exacerbate myasthenia symptoms. (Important to ask about antibiotic use history in patients that present with lid ptosis). Aminoglycosides are a class of antibiotics. Main action is on gram-negative aerobic bacteria. They disturb the 30s ribosomal subunit, preventing protein production. Gentamicin, Tobramycin, Amikacin, etc.

90 Tensilon - Edrophonium Used as a diagnostic for myasthenia gravis Edrophonium reversibly inhibits acetylcholinesterase The drug has a very brief duration of action (30 min) Adult 2mg IV. If no reaction give 8mg IV. To reverse atropine 10mg IM, and confirm with 2mg IM Child 1mg IV. If no reaction give an additional 1mg IV, up to 5mg

91 Tensilon - Edrophonium Adverse reaction Arrhythmia Bradycardia Hypotension Seizures Lacrimation Miosis Accommodative spasm Nausea

92 Medications for complications Adrenergics Epinephrine Antihistamines Promethazine Diphenhydramine Steroids Solu-Medrol Solu-Cortef

93 Complications Dr. Marrelli will have a class period dedicated to office emergencies

94 Syncope - Fainting Common in practice Older men with known heart disease Younger women prone to vasovagal episodes Reduced blood flow to the brain Increased peripheral vessel dilation Bradycardia (HR < 30-35) Tachycardia (HR > )

95 Syncope Patient will complain of Light-headedness Nausea Dizziness Sweating You may notice Change in skin color (pallor) Change in heart rate Sweating Rarely is there a loss of bladder/bowel control

96 Syncope What should you do Lay the patient down, keeping their feet above their head. This allows for blood to flow to their brain. These episodes are usually brief, so patients will regain consciousness

97 Syncope Workup History of postural hypotension History of heart disease, vascular disease Medication history (anti-hypertensive meds) History of heat exhaustion Check for carotid bruit Want to alert their MD/DO of the event if it is recurrent or a concern is found.

98 Hyperventilation Hyperventilation can occur when a patient in your office is under stress and becomes anxious. Leads to respiratory alkalosis, an increase in blood ph as carbon dioxide levels plummet. Patients will complain of light headedness, faint feeling and tingling of their extremities. Remove the anxiety causing factors. Do a neurological screening as hyperventilation can occur in some neurological situations.

99 Seizures There are many forms of seizures, and can occur at any time in patients that are susceptible. Patients can have jerking of body parts, loss of consciousness, and loss of bladder/bowel control. It is important for to maintain airway and ensure the patient does not harm themselves. Patients should be sent to their neurologist of the emergency room.

100 Myocardial infarction Risk factors include Age Hypertension Diabetes Cholesterol Smoking Patient complains of Pain (males > females) Difficulty breathing Weakness Cyanosis Sweating

101 Myocardial infarction This is a medical emergency If a MI is suspected, call emergency medical services (EMS) If the patient has lost consciousness, initiate CPR Use your AED!

102 The diabetic Hyperglycemia This is less likely to occur. If a patient has excessively high glucose and very little insulin, they can become acidotic Increase thirst and nausea Ketone breath Can go into a diabetic coma Hypoglycemia Too little glucose Have headache, dizziness, weakness, sweating Can go into diabetic shock Administer glucose and send on to the nearest hospital.

103 Anaphylaxis Type I, IgE mediated hypersensitivity reaction Acute systemic shock that can be life threatening Airways obstruction, hypovolemic shock, angioedema, and urticarial Immediate treatment includes epinephrine. Relaxes the bronchospasm via beta2 receptors, and constricts vasculature through alpha2 receptors 0.3mg epinephrine Kids 0.15mg epinephrine

104 Anaphylaxis Inject in the vastus lateralis and keep there for 10 seconds before removing.

105 Anaphylaxis If you have an emergency kit Get the epinephrine (1:1000), and administer mg SC/IM every 5-15 min as needed Follow with Diphenhydramine 25-50mg PO/IM/IV every 2-4 hrs as needed In addition administer Solu-Medrol IM/IV for longer term control of signs and symptoms (usually administered when they have arrived at the emergency room). During this time, keep the patient comfortable, hydrated, and if you have oxygen, administer at 6L/min.