| American Society of Anesthesiologists Task Force on Perioperative Visual Loss, the North American Neuro-Ophthalmology Society, and the Society for Neuroscience in Anesthesiology and Critical Care |
| Practice advisory for perioperative visual loss associated with prone spine surgery (updated report, 2019) |
- Preoperative preparation:
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- Inform patients that certain conditions (eg, male gender, obesity, vascular risk factors such as hypertension and peripheral vascular disease), may increase the risk of visual loss after prone spine surgery.
- Inform patients in whom prolonged procedures (>4 hours), substantial blood loss (>800 mL), or both, are anticipated that there may be an increased risk of perioperative visual loss.*
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- Intraoperative management:
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- Blood pressure management.
- Assess the patient's baseline blood pressure.
- Monitor blood pressure continually¶ in high risk patients.*
- Determine on a case by case basis whether deliberate hypotension should be used in high risk patients.*
- Check for the presence of preoperative hypertension, degree of blood pressure control, perioperative use of antihypertensive drugs, and the patient's risk of end-organ damage prior to using deliberate hypotension in a high risk patient.*
- Discuss the need for deliberate hypotension with the surgeon; use deliberate hypotension only when the anesthesiologist and surgeon agree that it is essential.
- Maintain higher arterial blood pressure levels in hypertensive patients.
- Treat prolonged significant decreases in blood pressure.
- Management of blood loss and fluid administration.
- Periodically monitor hemoglobin or hematocrit during surgery in high risk patients* who experience substantial blood loss. Transfuse blood as appropriate.Δ
- Administer crystalloids or colloids, alone or in combination, to maintain adequate replacement of intravascular volume.
- Use of vasopressors.
- Use adrenergic agents on a case-by-case basis, when it is necessary to correct for hypotension.
- Patient positioning.
- Position the head level with or higher than the rest of the body, and in a neutral forward position (ie, without significant neck flexion, extension, lateral flexion, or rotation) when possible.
- Avoid direct pressure on the eye to prevent retinal artery occlusion.
- Staging surgical procedures.
- Consider staging spine procedures in high-risk patients.*
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- Postoperative management:
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- Assess the vision of a high risk patient* when the patient becomes alert.
- If there is potential visual loss:
- Obtain urgent ophthalmologic consultation.
- Consider CT or MRI to rule out intracranial causes of visual loss and to visualize the optic nerves.
- Additional management may include optimizing hemoglobin or hematocrit, hemodynamic status, and arterial oxygenation.
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