Monitored anesthesia care by registered respiratory therapists during cataract surgery: an update.

OBJECTIVE: To reevaluate the safety and practicality of registered respiratory therapists (RRTs) providing monitored anesthesia care during cataract surgery. DESIGN: Prospective observational cohort study. PARTICIPANTS: A total of 15,440 consecutive patients undergoing phacoemulsification cataract surgery with intraocular lens insertion using topical anesthesia +/- intravenous (IV) sedation at 2 surgical centers. METHODS: Registered respiratory therapists, specially trained as anesthesia assistants, provided monitored anesthesia care during all stages of surgery, with an anesthesiologist immediately available for consultation as required. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of serious perioperative medical complications relating to the surgery and anesthesia. The secondary outcome measure was the rate (total and by stage of surgery) of anesthesiologist intervention, defined as consultation by the RRT to the attending anesthesiologist for any reason irrespective of the ultimate level of patient care rendered. Patient age and American Society of Anesthesiology (ASA) Physical Status (PS) score were also analyzed as potential predictors of the need for anesthesiologist intervention. RESULTS: There were no serious perioperative medical complications leading to death, endotracheal intubation, or postoperative hospitalization. A total of 395 cases (2.6%) required anesthesia intervention, with 257 (1.7%) occurring preoperatively, 140 (0.91%) occurring intraoperatively, and 5 occurring (0.03%) postoperatively. Seven cases required interventions at 2 different stages of surgery. Mean patient age in the anesthesiology intervention group (73.2 years) was greater than in the non-intervention group (71.2 years) (P = 0.0002), whereas patient age of > or =75 years correlated with a greater need for intervention (3.0%) than <75 years (2.2%) (P = 0.001). The mean ASA PS score was higher for cases requiring anesthesiology intervention (2.6) than for those not requiring intervention (2.2) (P<0.0001), and the intervention rate was significantly greater for cases with ASA ratings > or =3 (5.9%) compared with < or =2 (1.3%) (P<0.0001). CONCLUSIONS: We have demonstrated that allowing RRTs to provide monitored anesthesia care during cataract surgery with an anesthesiologist available as required seems to be both safe (no serious medical complications in 15,440 cases) and practical (anesthesiology intervention rate of 2.6%).

Monitored anesthesia care provided by registered respiratory care practitioners during cataract surgery: a report of 1957 cases.

OBJECTIVE: To evaluate the safety and feasibility of having monitored anesthesia care during cataract surgery provided by registered respiratory care practitioners (RRCPs). DESIGN: Retrospective case series. PARTICIPANTS: One thousand nine hundred fifty-seven consecutive patients undergoing cataract surgery at one surgical center between November 2001 and October 2003. METHODS: Phacoemulsification cataract surgery with intraocular lens insertion was performed using topical anesthesia, with or without IV sedatives. An RRCP, trained to function as an anesthesia assistant, provided monitored anesthesia care during all stages of surgery, with an anesthesiologist immediately available for consultation or assistance as required. MAIN OUTCOME MEASURES: The number of serious medical complications resulting from the anesthesia or surgery was measured. The rate of anesthesiologist intervention required at each stage of surgery--preoperative, intraoperative, and postoperative--was determined, along with the reasons for the interventions. Age, American Society of Anesthesiologists (ASA) risk class (a rating of preoperative physical status), and number of IV sedative agents given were analyzed as potential predictors of the need for anesthesiologist intervention. RESULTS: Among the 1957 cataract surgeries, there were no adverse medical events that resulted in death, hospitalization, or tracheal intubation. Two cases were aborted intraoperatively for medical reasons. A total of 78 cases (4.0%) required anesthesiologist intervention, with 34 (1.7%) requiring preoperative intervention, 43 (2.2%) requiring intraoperative intervention, and 3 (0.2%) requiring postoperative intervention; 4 cases required 2 separate interventions. The mean age of the intervention group (73.9 years) was statistically greater than that of the nonintervention group (71.0) (P = 0.02). A higher ASA rating (>2) correlated with an increased need for anesthesiologist intervention in terms of the total intervention rate (P<0.0001) and the intraoperative rate alone (P<0.0001). The use of more IV sedative agents (2 or 3 vs. 0 or 1) was marginally associated with a higher total intervention rate (P = 0.053) but not with a higher intraoperative intervention rate (P = 0.68). CONCLUSION: With the inherent safety of cataract surgery and the relatively low need for anesthesiologist intervention, we believe it is justified to allow RRCPs, trained as anesthesia assistants, to provide monitored anesthesia care during cataract surgery so long as anesthesiologist support is directly available when required. Potential benefits include cost savings in health care and decreased demand for anesthesiology services. To validate formally the preservation of patient safety from such a change in practice, however, a larger sample size would be required due to the inherently low rate of cataract surgery complications.