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1976 – Oh what a Year!!

In 1976 Steve Jobs and Steve Wozniak started a small computer company and called it Apple Computers. The first commercial supersonic Concorde flight took place between London and New York. The film “Rocky” was released and Jimmy Carter was elected president of the USA. NASA’s Viking 1 Lander touches down on Mars and they also reveal their prototype space shuttle called “The Enterprise”. Abba, the Eagles, Queen and David Bowie helped create the sounds of 1976.

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At the same time, Margaret Piehl was a nurse working in a small community hospital ICU in America. She noted that when patients with acute respiratory distress syndrome (ARDS) were placed in the prone position their oxygenation levels improved. Margaret described this phenomenon in a ground-breaking paper published in Critical Care Medicine in 1976. Together with physician Robert Brown she described the improvements in arterial oxygenation on 5 patients brought about by “extreme position changes”(1)

In the following years other physicians studied this observation to understand who would benefit from the technique, when it should be carried out and how long a patient should be in the prone position. It took many years of clinical trials to confirm that prone positioning improves arterial oxygenation. Finally in 2013 the PROSEVA(2) trial was published in the New England journal of Medicine. This trial showed that early intervention with the use of prone positioning in ARDS patients with the most severe hypoxemia resulted in a 17% absolute reduction in mortality. Prone positioning has the most impact on survival of ARDS patients than any other intervention. Thank you, Margaret Piehl, for your keen eye back in 1976.

For over 40 years this remarkable but simple technique has helped save the lives of many ARDS patients in ICU and the world barely noticed. Scroll forward to 2020 and Covid 19 sweeps across the globe. Images appear on our TV screens of ICU’s full of desperately ill Covid 19 patients being treated by incredible nurses and doctors. ARDS is often associated with Covid 19, resulting in many patients being proned. We see proning in action and start to take an interest in Margaret Piehl’s observation.

So, what is proning, how is it carried out and how does it prevent any patient, with ARDS, whether they have Covid 19 or not, from dying.

Proning is a manual handling procedure where a patient’s position is changed, so they are lying on their front, face down, in a “prone” position. The aim is to change the way the patient is resting, which is usually going from lying on their back to their front and back again. That sounds quite straight forward. All you have to do is move the patient from lying on their back to lying on their stomach.

But they probably have Covid 19 with associated ARDS and are sedated. They will be on a ventilator, and they may have a chest drain, cannulas and ECG leads in place.

You begin with the patient in this position with all the attached leads etc

The Intensive Care Society
The Intensive Care Society

And end up with them in a prone position

The Intensive Care Society
The Intensive Care Society

It can be quite a complicated manoeuvre that is described brilliantly in the Intensive Care Society Guidelines for Prone Positioning in Adult Critical Care(3):

  • You need at least 5 trained healthcare professionals with someone taking control at the head of the patient.
  • Staff are allocated to manage the airway and the drains etc. and are positioned along the side of the patient.
  • The patient is on a clean sheet with a slide sheet underneath.
  • Pillows are placed strategically on the patient who is then covered with another sheet leaving the head and neck free.
  • The edges of the top and bottom sheets are rolled together to tightly wrap the patient.
  • The patient is then moved to the edge of the bed and turned through 90°, so they are lying on their side.
  • The rolled-up sheet is pulled up from beneath the patient whilst the patient is carefully turned into the prone position.
  • All the leads and ETT are checked to ensure they are not kinked.
  • The patients’ arms are placed in the “swimmers” position, head turned to one side, and they are nursed at 30° in the reverse trendelenburg position.

Most hospitals maintain patients in a prone position for at least 12 hours per day, though practices vary. Throughout the time the patient is in the prone position, the head and arms are moved regularly to prevent pressure damage. This requires at least 3 healthcare professionals including an anaesthetist at the top of bed to manage the airway when changing head position. Proning sessions continue until there is a sustained improvement in oxygen levels, or if proning does not improve oxygen levels.

AP: Zhang Yuwei via Xinhua
AP: Zhang Yuwei via Xinhua

With all this extra workload in ICU, caring for seriously ill Covid 19 patients, it doesn’t surprise me when I hear that ICU staff are exhausted. This is a demanding role and ICU staff deserve the highest praise from us all.

Prone positioning can help a severely ill Covid 19 patient in many ways:

  • In the supine position, the lungs are compressed by the heart and abdominal organs. Gas exchange is reduced in areas of collapsed lung, resulting in low oxygen levels. In the prone position, lung compression is less, improving lung function.
  • The body has mechanisms to adjust blood flow to different portions of the lung. In ARDS, an imbalance between blood and air flow develops, leading to poor gas exchange. Prone positioning redistributes blood and air flow more evenly, reducing this imbalance and improving gas exchange.
  • With improved lung function in the prone position, less support from the ventilator is needed to achieve adequate oxygen levels. This may reduce risk of ventilator-induced lung injury, which occurs from overinflation and excess stretching of certain portions of the lung.
  • Prone positioning may improve heart function in some patients. In the prone position, blood return to the chambers on the right side of the heart increases and constriction of the blood vessels of the lung decreases. This may help the heart pump better, resulting in improved oxygen delivery to the body.
  • Because the mouth and nose are facing down in the prone position, secretions produced by the disease process in the lung may drain better.

The benefits of proning severely ill patients are very clear but there are risks associated with the procedure. Placing patients in this position may put them at risk for complications such as pressure injuries, airway complications, facial injuries, peripheral nerve injuries, musculoskeletal injuries, and cognitive impairment.

The Intensive Care Society Guidelines(3) recommend that there should be no direct pressure on the eyes. Unfortunately, this is not always possible and prone nursed patients may suffer direct pressure on the eyes or raised orbital/ophthalmic pressure due to gravitational effects or periocular swelling. This can cause number of complications including acute primary angle closure glaucoma, ischaemic optic neuropathy, vascular occlusion, orbital apex syndrome and corneal abrasions. In a busy ICU full of seriously ill patients taking care of the proned patients’ eyes can be missed. Eye care can contribute enormously to improved patient recovery by ensuring the eyes are not painful or swollen and vision isn’t blurred. Additionally, painful corneal abrasions and infections are avoided.

The Intensive Care Society Guidelines(3) recommend that prior to proning, the eyes are assessed, cleaned, ointment applied and then covered with eye coverings. Eye condition should be checked every 2 to 4 hours and corneal clarity checked.

It surely makes sense that the eye covering of choice in this situation should be EyePro.™ which has clear advantages over micropore tape. EyePro™ is sterile and ensures rapid, complete, and safe eyelid closure. By sealing around the eye circumferentially, all moisture is retained, thus preventing the eye from drying out.

Additionally, a clear central window allows direct observation of eyelid closure. EyePro™ was specifically designed for one purpose; to protect the eyes during general anaesthesia. In doing so, EyePro™ provides a superior level of protection against corneal abrasions.

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References:

  1. Piehl MA and Brown RS. Use of extreme position changes in acute respiratory failure. Critical Care Med 1976;4(1):13-14. 
  2. PROSEVA trial: Prone positioning in severe ARDS. New Engl J Med 2013;368(23):2159-2168.
  3. The Intensive Care Society Guidelines for Prone Positioning in Adult Critical Care. Published November 2019.
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Author: Niall Shannon, European Business Manager, Innovgas

This article is based on research and opinion available in the public domain.

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Corneal Abrasion; problem what problem?

Well, it all depends on which side of the fence you are sitting on. Most medical definitions describe a corneal abrasion as a painful scrape or scratch on the surface of the clear part of the eye. This clear tissue of the eye is known as the cornea, the transparent window covering the iris, the circular coloured portion of the eye. Descriptions also state that in most cases the cornea heals in a couple of days and all symptoms pass.

A patient on the other hand would probably describe a corneal abrasion as painful to say the least. In fact, it may be extremely painful. This is because the cornea has a high concentration of nerve endings, so it is going to be really painful. Alongside the extreme pain they may feel as though there is something in their eye. The eye will look red, vision will be blurred and there will be excessive tearing. They may be sensitive to light but closing the eye may only cause the pain to intensify. There may be vision loss and headaches which will cause concern.

So, this can be an extremely uncomfortable situation for someone to be in and they need treatment immediately to relieve the pain and allow them to see clearly.

How does a corneal abrasion occur? The answer is, quite easily. Minor abrasions can be caused by:

  • Poking your eye with a fingernail, pen, or makeup brush.
  • Rubbing it too hard.
  • Wear poor-fitting or dirty contact lenses or wearing them for too long.
  • Walking into something like a branch of a tree.

More serious abrasions can occur from:

  • Getting chemicals in your eye.
  • Get dirt, sand, sawdust, ash, or some other foreign matter in your eye, especially at work and not wearing eye protection.
  • Play sports or engaging in high-risk physical activity without eye protection.

You may be surprised to learn that a corneal abrasion can occur when you are having an operation and are anaesthetised. How can that possibly happen, you are probably thinking. Again, the answer is quite easily. But before we consider how a corneal abrasion can occur in the operating theatre, we need to look at how the eye behaves when it is anaesthetised, and the steps taken to protect your eyes when you have an operation.

A general anaesthetic can have several effects on your eyes, including:

  • It can cause lagophthalmos which is a failure of the eyelids to fully close. During normal sleep, lid closure is maintained by the tonic contractions of the orbicularis muscle. Lagophthalmos only occurs in about 4% of people during normal sleep. However, under anaesthesia one study demonstrated that 59% of patients failed to have complete eyelid closure.(1)
  • Tear production and stability are significantly reduced which causes the cornea to dry out.
  • Bell’s phenomenon is a protective mechanism that turns the eyes upwards to protect the cornea. It occurs naturally during sleep, but this mechanism is also lost during general anaesthesia.

Therefore, you can see that the eyes are compromised when you are given a general anaesthetic and so must be protected from being damaged. But how common is getting a corneal abrasion in the operating theatre, what causes it and what is done to protect the eyes?

A corneal abrasion is the most frequent ocular complication of general anaesthesia.(2) The American Society of Anaesthesiologists’ closed claims analysis of ocular injuries associated with general anaesthesia, 35% were corneal abrasions, of which 16% resulted in permanent ocular damage.(3)

Because the eyes are compromised during general anaesthesia, almost anything can cause a corneal abrasion. The list is endless. A watch strap, name badge, the anaesthetist’s hands, facemasks, drapes, instruments laryngoscope, skin preparation solutions, or the direct irritant effect of inhalational anaesthetic agents. In recovery the eye may be injured by face masks, the patient’s fingers, or the bed linen. However, most corneal abrasions are caused by the failure of the eyelids to close properly leading to corneal drying.(4) I will return to this point later.

It’s clear that the eyes need some solid protection to prevent them from being damaged. So, what is done in today’s modern, high tech expensive operating theatre? They do this.

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Usually, a theatre technician will use some general-purpose tape that is lying on a trolley or in their pocket and your eyes will be taped shut. Prior to taping a protective ointment or gel may be applied. However, we all know that adhesiveness of tape varies and that used in the operating theatre is no different. Too little stick may not ensure or maintain complete eyelid closure, leading to moisture loss from the eye. Too much stick may cause eyelid bruising, irritation and skin tears or eyelash loss on removal. Tape used is usually opaque making it difficult to tell if the patients’ eyes are completely closed. Frequent removal and reapplication of the tape makes it less sticky and prone to falling off Additionally, the anaesthetist may need to check pupil dilation and the tape needs to be removed and reapplied whilst wearing surgical gloves. Not an easy thing to do!

So, back to our patient. Despite taping the patient’s eyes being taped during an operation, the tape was opaque, and no one spotted that the eyes opened during the operation causing the cornea to dry out. When the patient woke up, they had a really painful and sore red eye. A saline washout of the eye was tried but that didn’t work. In the end an ophthalmologist was called to examine the patient and a corneal abrasion, caused by the eye drying out was diagnosed. This required treatment including pain management, antimicrobial prophylaxis, a pressure patch, and close monitoring meaning the patient was in hospital for an extra day.

Could all this have been avoided? Could the anaesthetist have spotted that the patients’ eyes had opened during the operation and closed them? Could a corneal abrasion have been avoided and the patient not had such a painful experience? Could the hospital have avoided all those extra treatment costs such as consultant time, drugs, and bed usage?

Instead of using opaque general-purpose tape to protect the patients’ eyes, the hospital should have used EyePro™ instead.

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Why should we use EyePro™ instead of tape?  EyePro™ is a unique eyelid cover designed by an anaesthetist to maintain eyelid closure during general anaesthesia.

It ensures rapid, complete, and safe eyelid closure. By sealing around the eye circumferentially, all moisture is retained, thus preventing the eye from drying out. Additionally, a clear central window allows direct observation of eyelid closure.

EyePro™ has a patented dual zone design whereby an inner transparent window allows intra-operative assessment of eyelid closure, while an outer, more rigid, opaque zone allows for easy handling and excellent conformity to the eye socket. The inner window has a gentle adhesive which helps to maintain eyelid closure and reduces eyelid trauma and/or eyelash removal. The outer zone has slightly stronger adhesive that maintains eyelid closure for extended periods. Also, non- adhesive tabs allow for easy handling, application, and removal, even while wearing gloves.

Additionally, each pair of EyePro™ comes packaged together in a sterile wrap to decrease the risk of cross contamination. In a world where we are going to have to live with Covid-19 anything that reduces the risk of infection must be a good thing. But that will be the subject of another article.

EyePro™ is more expensive than tape I hear you say. Yes, it is. That’s because it has been specifically designed for one purpose; to protect the eyes during general anaesthesia. In doing so, EyePro™ provides a superior level of protection against corneal abrasions. And don’t forget those extra treatment costs such as consultant time, drugs, and bed usage. An extra day in hospital would cost approximately $1800/day in the USA, $AUD1000/day in Australia, £400/day in the UK and €600 in the EU.

EyePro™ is a major advance in keeping the patients’ eyes safe during general anaesthesia. Remember, most corneal abrasions are caused by the failure of the eyelids to close properly leading to corneal drying. EyePro™ allows the anaesthetist to ensure the eyes remain closed, thereby reducing the risk of corneal abrasion. This leads to a better patient experience, quicker recovery time and a reduction in the use of valuable hospital resources such as drugs, bed occupancy and clinical time. Additionally, within the overall cost of treating the patient EyePro™ could also save you money. It really is a no brainer!!!

References:

  1. Batra YK & Bali IM. Corneal abrasions during general anaesthesia. Anaesthesia and Analgesia 1977; 56: 363– 5.
  2. Terry TH, Kearns TP, Grafton‐Loue J, Orwell G. Untoward ophthalmic and neurological events of anaesthesia. Surgical Clinics of North America 1965; 45: 927– 9.
  3. Gild WM, Posner KL, Caplan RA, Cheney FW. Eye injuries associated with anaesthesia. Anaesthesiology 1992; 72: 204– 8.
  4. White E, Crosse MM. The aetiology and prevention of peri‐operative corneal abrasions. Anaesthesia, 1998, 53, pages 157–161
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Author: Niall Shannon, European Business Manager, Innovgas

This article is based on research and opinion available in the public domain.