title: Outpatient cataract surgery: incident and procedural risk analysis do not support current clinical ophthalmology guidelines.
abstract: OBJECTIVE
  To evaluate whether an ophthalmologist-led, non-anesthesia-supported, limited monitoring pathway for phacoemulsification/intraocular lens cataract surgery, can be performed safely with only a medical emergency team providing support.
  
  
  METHODS
  Retrospective, observational, cohort study.
  
  
  METHODS
  All patients who underwent elective phacoemulsification/intraocular lens surgery under topical anesthesia in the ophthalmology outpatient unit between January 1, 2011, and December 31, 2012.
  
  
  METHODS
  Cataract surgery was performed by phacoemulsification under topical anesthesia. The intake process mainly embraced ophthalmic evaluation, obtaining a medical history, and proposing the procedure. A staff ophthalmologist performed the procedure assisted by 2 registered nurses in an independent outpatient clinic operating room within the hospital. The clinical pathway was without dedicated presence of or access to anesthesia service. Perioperative monitoring was limited to blood pressure and plethysmography preoperatively and intraoperatively. Patients were offered supportive care and instructed to avoid fasting and continue all their chronic medication.
  
  
  METHODS
  The primary outcome measure was the incidence of adverse events requiring medical emergency team (MET) interventions throughout the pathway. Secondary outcome measures were surgical ocular complication rates, use of oral sedatives, and reported reasons to perform the surgery in the classical operation room complex.
  
  
  RESULTS
  Within the cataract pathway, 6961 cases (4347 patients) were eligible for analysis. Three MET interventions related to the phacoemulsification/intraocular lens pathway occurred in the 2-year study period, resulting in an intervention rate of 0.04%. None of the interventions was intraoperative. All 3 patients were diagnosed as vasovagal collapse and recuperated uneventfully. No hospital admittance was required. Eight other incidents occurred within the general ophthalmology outpatient unit population during the study period.
  
  
  CONCLUSIONS
  Cataract surgery can be safely performed in an outpatient clinic, in the absence of the anesthesia service and with limited workup and monitoring. Basic first aid and basic life support skills seem to be sufficient in case of an adverse event. An MET provides a generous failsafe for this low-risk procedure.
authors.affiliation: Department of Anesthesiology & Resuscitation, St. Elisabeth Hospital, Tilburg, the Netherlands. Electronic address: j.koolwijk@elisabeth.nl.
authors.forename: Jasper
authors.initials: J
authors.lastname: Koolwijk
authors.affiliation: Department of Ophthalmology, St. Elisabeth Hospital, Tilburg, the Netherlands.
authors.forename: Mark
authors.initials: M
authors.lastname: Fick
authors.affiliation: Department of Surgery, St. Elisabeth Hospital, Tilburg, the Netherlands.
authors.forename: Caroline
authors.initials: C
authors.lastname: Selles
authors.affiliation: Department of Surgery, St. Elisabeth Hospital, Tilburg, the Netherlands.
authors.forename: Gökhan
authors.initials: G
authors.lastname: Turgut
authors.affiliation: Department of Anesthesiology & Resuscitation, St. Elisabeth Hospital, Tilburg, the Netherlands.
authors.forename: Jeske I M
authors.initials: JI
authors.lastname: Noordergraaf
authors.affiliation: Department of Ophthalmology, St. Elisabeth Hospital, Tilburg, the Netherlands.
authors.forename: Floor S
authors.initials: FS
authors.lastname: Tukkers
authors.affiliation: Department of Anesthesiology & Resuscitation, St. Elisabeth Hospital, Tilburg, the Netherlands.
authors.forename: Gerrit J
authors.initials: GJ
authors.lastname: Noordergraaf
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000556:Ambulatory Surgical Procedures / Q000592:standards*; D000772:Anesthesia, Local / Q000379:methods; D016292:Procedural Sedation / Q000379:methods; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D019654:Lens Implantation, Intraocular; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D009885:Ophthalmology / Q000592:standards*; D018918:Phacoemulsification / Q000009:adverse effects / Q000592:standards*; D017410:Practice Guidelines as Topic / Q000592:standards*; D012189:Retrospective Studies; D018570:Risk Assessment; D019462:Syncope, Vasovagal / Q000453:epidemiology / Q000209:etiology
chemical_list: D006993:Hypnotics and Sedatives