Care of the Patient Undergoing Anaesthesia - Essay Example

of the of the Concerned Nursing 30 March Case study: Patient undergoing anaesthesia The principles and practices ofanaesthesia that are followed in a patient undergoing surgery under general anaesthesia have been illustrated in detail in the following case study. Introduction An eighteen year old female, educated up to high school and working as a sales girl in a local department store, presented with complaints suggestive of symptomatic gall stone disease which was confirmed on the ultrasound. The decision to perform laparoscopic cholecystectomy under general anaesthesia was taken by the surgeon. Patient was referred to the pre-anaesthetic check up (PAC) clinic where she was evaluated and given a PAC form with clearance for general anaesthesia. Preoperative assessment Pre anaesthetic assessment followed the standard protocol of history taking, physical examination and investigations. Apart from off and on abdominal pain with nausea for the past 3 months, no other complaints were elicited. There was no history of jaundice. Questions pertaining to other systems (cardiac, respiratory, neurological, endocrine) revealed no abnormality. There were no positive histories of drug allergies, previous surgery, drug addiction, smoking or alcohol abuse. Patient had no active respiratory tract infection. Her vital parameters (weight, heart rate, blood pressure, temperature, and respiratory rate), general physical examination (no pallor, icterus, cyanosis, lymphadenopathy, pedal oedema) and systemic examination were within normal limits. Airway assessment predicted no difficulty in airway management. As the surgeons had already gotten her liver function tests done, which were normal, no additional investigations in a young healthy female without associated co-morbidities were required and the patient was classified as ASA grade I. Patient was briefly explained about the anaesthetic procedure and all her queries were satisfactorily answered. She wasn’t overtly anxious, but she did express her apprehensions regarding the degree to which the procedure was likely to be painful. She was explained that the necessary pain medications will be given to her and best possible efforts in this regard would be done. A written and informed consent for anaesthesia was obtained. Thus, patient’s physiological as well as psychological needs were well addressed (Miller et al 2009). Pre operative instructions were explained to the patient verbally and were mentioned on her PAC form as well. She was instructed to bring the PAC form along with all other clinical documents and report to the preoperative holding area in the morning at a specified time on the day of surgery accompanied with a responsible adult as an attendant. Her pre-op orders included fasting orders (nil per oral) for 8 hours prior to surgery, a mild anxiolytic tablet and aspiration prophylaxis tablet (antacid) to be taken the night before surgery and in the morning with a sip of water. (Miller et al 2009). Anaesthetic procedure As the patient had been administered only a mild anxiolytic and no sedatives, she arrived walking in the preoperative area on the morning of the scheduled date. Her PAC form was reviewed and she was enquired about any fresh complaints. Her vital parameters were recorded along with temperature at the tympanic membrane. She was found to be afebrile (36.5?C). She was asked to change into OT clothes and was then shifted inside for induction of anaesthesia. Theatre preparation had been done prior to arrival of the patient inside. This involved maintaining the ambient temperature (22?C in this case) and humidity levels and anaesthesia machine, medication and resuscitation equipment check. Anaesthetic equipment was checked in accordance with the guidelines currently in use issued by the Association of Anaesthetists of Great Britain and Ireland. Alarm limits on the monitor were set according to the patient. Drugs for anaesthesia were prepared, labelled and kept on the workstation. Emergency cart was checked for resuscitation drugs and equipment. Airway cart was checked and the presence of necessary laryngoscope blades, oral airways and ET tubes was ensured (The Association of Anaesthetists of Great Britain and Ireland 2004). Patient was signed in according to the WHO checklist by the nurse and the anaesthetist, as specified in the ‘prior to induction’ column (WHO 2009). Basic monitors such as ECG leads and electrodes, non invasive blood pressure (NIBP) cuff and pulse oximeter (SpO2) probe were applied and baseline parameters were recorded. Intravenous access was secured with a 20 G IV cannula on the non dominant arm and it was connected to a one litre bag of Hartman solution following all aseptic precautions. IV fluid requirement was calculated based on the patient’s weight, requirement during induction of anaesthesia, fasting and maintenance requirements and the nature of the surgical procedure and an IV infusion was accordingly started. Induction After completion of the checklists, application of basic monitoring and establishment of IV access, patient became ready for induction. Oxygen on the anaesthesia workstation was turned on at the rate of 6 litres per minute and patient was preoxygenated with 100% O2 via facemask with gentle but close apposition and the patient was instructed to breathe in and out calmly. Meanwhile, patient was given 100 microgram IV Fentanyl and injection Propofol was started for induction. A total of 200 mg Propofol, administered in titrated doses, was required for induction and as soon as induction happened, which was made certain by patient becoming unresponsive to verbal commands, patient was checked for mask ventilation. Once the anaesthetist was able to mask ventilate, Atracurium 40 mg as muscle relaxant was administered and patient was mask ventilated for 2 minutes. Simultaneously, Sevoflurane vaporiser dial was turned on at 2% concentration to maintain the depth of anaesthesia. On achievement of muscle relaxation, laryngoscopy was performed with Macintosh blade no. 3 and cuffed endotracheal tube of 7 mm ID was used to secure the airway. ET tube was inserted up to a depth of 22 cm and cuff was inflated with 5 ml of air. It was ensured that no leaks around the cuff were present. Bilateral air entry was confirmed with auscultation and end tidal CO2 waveform and then the tube was secured. Eyes were protected by taping shut with micropore tape. An orogastric tube was inserted to facilitate stomach aspiration, if required by the surgeon, for adequate visualization of the intra-abdominal organs. Patient was shifted to OT table carefully by 4 people using Patslide. Pressure areas were padded using pillow, gamgee and jelly pads. A nasopharyngeal temperature probe was inserted to monitor core temperature and Bair Hugger was employed for the maintenance of temperature and to prevent hypothermia. Maintenance Anaesthesia was maintained with air (500ml per minute) and oxygen (500ml per minute) mixture with Sevoflurane at 2% concentration to maintain a minimum alveolar concentration (MAC) of 1.1. Positive pressure ventilation was done using a closed circle circuit and CO2 absorber. Special attention was paid to end tidal carbon dioxide concentration to prevent CO2 retention, which can happen in laparoscopic procedures employing CO2 gas for insufflations purposes. Tidal volume and respiratory rate were adjusted for appropriate maintenance of these levels. Intraoperatively, patient’s ECG, heart rate, oxygen saturation and capnography waveform were continuously monitored and NIBP was recorded at least every 5 minutes. Anaesthesia record printout was obtained electronically from the workstation at the end of the procedure. Intraoperatively, patient was given 5 mg Morphine and 1 gram Paracetamol IV infusion to supplement analgesia. Top-up dose of muscle relaxant was not required in this patient. Towards the end of the procedure, anti-emetic prophylaxis was given with injection Dexamethasone 3.3 mg and injection Ondansetron 4 mg. Reversal After the removal of the gall bladder, desufflation and closure of the laparoscopic ports, patient was prepared for reversal and extubation. Sevoflurane vaporiser was switched off, 100% O2 was started and the rate of O2 at the flow meter was increased to 6 litres per minute. Five mg morphine was administered to ensure adequate pain relief and smooth extubation. As soon as partial recovery of muscle power was evident, patient was reversed with injection Glycopyrrolate 0.5 mg and Neostigmine 2.5 mg. Subsequently, ET tube was removed when patient recovered consciousness, exhibited spontaneous and adequate breathing efforts and satisfied the extubation criteria. 100% oxygen was administered for few minutes via face mask and patient was shifted to the recovery or the post anaesthesia care unit (PACU). Post anaesthesia care unit Patient was observed in PACU for an hour. She was made to lie propped up in the bed with 40% O2 delivered through a venturi mask. Her blood pressure, heart rate and oxygen saturation were monitored during her stay in the PACU. She was assessed for pain according to the VAS score and patient was found to be satisfied with the degree of pain relief. There was no complaint of nausea, patient was conscious and oriented with adequate muscle power, and clinically and haemodynamically stable. After a final assessment by the anaesthesiologist, the patient was shifted to the surgical ward. Discussion Certain standards and protocols have been established for the safe conduct of anaesthesia and adherence to these protocols and practices is expected from an anaesthesia provider to provide optimal patient care. As we review the above mentioned case, we determine that every step and procedure is backed by a rationale and can be easily and scientifically explained. An 18 year old female has been introduced with social, physiological and pathological details. Patient’s age, qualification and socioeconomic status have been provided along with her medical and surgical condition described briefly. Patient’s age has a bearing on her clinical condition and her education status can help the physician to communicate with her accordingly. Pre anaesthetic assessment is pertinent to gather information about patient’s health status and reveal any comorbid illnesses that may have anaesthetic implications. Correspondingly, the anaesthetist formulates the plan for anaesthesia and the patient’s consent can be obtained about that plan, after being explained about the risks and the alternative options available. Also, patient’s psychological needs are addressed and patient can be counselled about any fears or anxiety regarding the anaesthetic procedure (Miller et al 2009). In preoperative orders, patient was advised to remain fasting for 8 hours prior to surgery as it was an electively scheduled surgery. There is an increased risk of gastric content aspiration in upper abdominal as well as laparoscopic surgeries because of increased intra- abdominal pressure. Additionally, an antacid (ranitidine) tablet was prescribed to reduce the pH of gastric contents. An anxiolytic was also prescribed as a part of premedication and she was instructed to be accompanied by another adult. Operation theatre was prepared for surgery prior to the arrival of patient inside the theatre. Anaesthetic issues of concern were maintenance of ambient temperature and availability of devices for active warming of the patient such as Bair hugger. Additionally, pads were required for the protection of vulnerable pressure points. Inadequate padding can cause serious nerve injuries resulting in motor and sensory deficits. Also, care was taken that adequate number of personnel were employed to shift the patient and patslide was used for this purpose. The most important part of theatre preparation is anaesthetic equipment check. In this checklist, electricity supply and battery backup of the anaesthesia machine is checked. Minimum mandatory monitors such as pulse oximeter, oxygen analyser and capnograph are checked and their alarm limits are set. Pipeline supply of oxygen and other anaesthetic gases and their connections are checked. Adequate supply of oxygen in the reserve cylinder is ensured. Parts of the anaesthesia machine including flow meters, vaporisers, CO2 absorber and breathing circuits are checked. Scavenging system’s functioning is checked. Other ancillary equipment such as instruments for airway management, suction apparatus and self inflating bag (e.g. AMBU) are checked. Finally, all these checks are documented on the patient’s anaesthetic record as done. These minimum checks are done before any new case as patient’s life under the influence of anaesthetic drugs is always at risk. A little malfunction in any part of the machine, oxygen supply or inability to secure the airway of the patient can result in inability to ventilate the patient or delivery of a hypoxic gas mixture causing death of the patient or permanent hypoxic brain damage within minutes. These catastrophic outcomes can be prevented only by continuous vigilance and regular maintenance of anaesthetic equipment by the anaesthesia staff. (The Association of Anaesthetists of Great Britain and Ireland 2004) On arrival, her pre anaesthetic assessment was reviewed. Patient was signed in according to the Surgical Safety Checklist issued by World Health Organization prior to induction of anaesthesia. This checklist confirms the identity of the patient and warns about any additional risk that the patient may have of developing anaphylaxis, aspiration or major blood loss. (WHO 2009) All monitoring standards, as described later, were followed before the start of and during anaesthesia. IV access was secured to administer drugs and fluids. Patient was preoxygenated with 100 % O2 for 3 minutes. This procedure causes denitrogenation and replaces air in the alveoli with oxygen. This increases the allowable apnoeic period and buys time for any airway intervention if required (McCrory & Matthews 1990). Intravenous induction was performed in this case, employing a judicious combination of opioid and hypnotic agent. Fentanyl is an opioid with rapid onset of action, which, when combined with Propofol, rapidly induces sleep. Its combination with the hypnotic agent decreases the induction dose of propofol, provides haemodynamic stability and attenuates the pressor response associated with laryngoscopy and intubation. Propofol too was an ideal induction agent for this case because of its rapid onset, brief duration of action, absence of residual sedation, significant side effects or contraindications. Muscle relaxant Atracurium was also an intermediate acting agent suitable for this surgery (Barash, Bruce & Stoelting 2006). It was administered only after patient’s mask ventilation could be confirmed with bag and mask, followed by manual ventilation of the patient for 2 minutes. Laryngoscope blade no.3 was used to visualise the vocal cords and adequate relaxation of vocal cords allowed negotiation of endotracheal tube into the trachea. General anaesthesia with a secured airway is preferred for upper abdominal laparoscopic procedures as these patients are at a higher risk of regurgitation and aspiration. An orogastric tube was also inserted to prevent the same. A cuffed endotracheal tube is still considered as the gold standard for securing the airway in patients under general anaesthesia under risk of aspiration. Its presence in trachea was confirmed by capnography waveform. It was secured at a reasonable and adequate depth so that it stayed in the trachea and did not become endobronchial. Eyes were protected from abrasions, dryness and inadvertent injury by closing them with tape. Maintenance of anaesthesia was done with Sevoflurane which is an inhalational anaesthetic agent with rapid onset and offset of action, appropriate for a short procedure like laparoscopic cholecystectomy. Amnesia is one of the integral aspects of anaesthesia along with analgesia and muscle relaxation. Inadequate concentration of anaesthetic agent can cause awareness (Barash, Cullen & Stoelting 2006).1.1 MAC of Sevoflurane was achieved in a 50%-50% mixture of air and oxygen at a total flow rate of 1litre per minute. Intraoperatively, analgesia was provided with 5 mg Morphine and 1gm Paracetamol. Laparoscopic procedures are believed to be associated with less pain as compared to open incision surgeries as the size of incision is smaller in laparoscopic procedures. Thus, the type and dose of analgesics was satisfactory for the surgery. Young females may have a slightly higher incidence of postoperative nausea and vomiting, so the patient was given antiemetic prophylaxis with Dexamethasone and Ondansetron. Towards the end of the procedure, inhalational agent was switched off to allow awakening which occurs quickly with Sevoflurane. Similarly, to reverse the effect of muscle relaxant, Neostigmine was given (Barash, Cullen & Stoelting 2006). Glycopyrrolate has to be given along with Neostigmine to counter its cholinergic side effects such as bradycardia, bronchospasm and increased salivation. Extubation was done only when the patient satisfied the extubation criteria and it could be ensured that patient can protect her airway and maintain adequate ventilation. Morphine also allowed for a smooth extubation without coughing and bucking. 100% oxygen was given through facemask to make up for the time taken to transport the patient from operation theatre to recovery. Patient was monitored in recovery and she was shifted to the ward only when clinical stability was confirmed Standards of monitoring during anaesthesia Minimum monitoring standards have been established for the care of patient under anaesthesia and following recovery. These were followed in the case presently being discussed. Succinctly put, the first standard requires that a qualified anaesthetist must be present throughout the conduct of anaesthesia, be it general or regional anaesthesia or monitored anaesthesia care. Oxygen analyser with an audible alarm, capnography and inhalational agent analyser are considered essential. Essential monitoring devices should be attached to the patient before the induction of anaesthesia and continued throughout the procedure. Apart from this, patient’s clinical status should be continuously evaluated in the context of ventilation, oxygenation and circulation and this clinical data should be recorded at an interval of no less than 5 minutes, and more frequently if required. All the data pertaining to clinical status of the patient should be documented on patient’s anaesthetic record chart, preferably generated electronically. (The Association of Anaesthetists of Great Britain and Ireland 2007). All of this essential monitoring was performed in this case and an anaesthesia record chart was generated. Special considerations for anesthesia for laparoscopic surgery In abdominal laparoscopic surgeries, due to creation of pneumoperitoneum, many ventilatory and haemodynamic alterations can occur. These alterations are compounded by the special positioning required for laparoscopic cholecystectomy. Because of a rise in intra- abdominal pressure (IAP), it may be difficult to ventilate the patient. This, along with absorption of CO2, can cause respiratory acidosis leading to delayed awakening. Haemodynamically, decreased venous return to the heart may be caused by raised IAP leading to hypotension. Alternatively, hypercarbia may cause hypertension. Thus, it is imperative that patient’s ventilation should be controlled and adjusted accordingly and blood pressure should be regulated (Miller et al 2009). Sudden decrease in heart rate and venous gas embolism may occur at the time of commencement of insufflation and thus, close monitoring is required. Also, chances of endotracheal tube becoming endobronchial are there, which necessitates that airway pressure monitoring and regular auscultation of bilateral breath sounds should be done. (Miller et al 2009) Conclusion Safe conduct and care of a patient under anesthesia is an art. It’s not merely an act of putting the patient to sleep for surgery. It is fraught with a huge potential for complications and there is no scope for mistakes, carelessness and negligence. An anaesthesia provider is committed to provide his or her patient utmost standards of safety, psychological as well as physical comfort and amnesia. This can be achieved only if anaesthetist’s knowledge about his patient (pre-anaesthetic assessment) and his field of work (anaesthetic and resuscitation equipment, standards of anaesthesia monitoring, physiology, pharmacology, sub-speciality management and conduct of anaesthesia) is complete. In addition, operating field condition, so far as anaesthesia is concerned, should be such that the surgeon can do his best. Once these fundamentals are understood, the quality of care given to a patient under anaesthesia will be greatly enhanced. Reference List Barash, Paul G, Cullen, Bruce F & Stoelting, Robert K 2006, Clinical Anaesthesia, Lippincott Williams & Wilkins, London. McCrory, JW & Matthews, JNS 1990, ‘Comparison of Four Methods of Preoxygenation’, British Journal of Anaesthesia, Vol. 64, pp. 571-574. Miller, D Ronald, Eriksson, Lars I, Fleisher, Lee A, Weiner-Kronish, Jeanine & Young William 2009, Miller’s Anaesthesia 7th Edition, Churchill Livingstone, New York. The Association of Anaesthetists of Great Britain and Ireland 2004, Checklist of Anaesthetic Equipment, viewed 29 March 2012, . The Association of Anaesthetists of Great Britain and Ireland 2007, Recommendation for Standards of Monitoring during Anaesthesia and Recovery, viewed 29 March 2012, . World Health Organization 2009, Surgical Safety Checklist, viewed 29 March 2012, . Read More