Non-Scheduled Perioperative Care - Essay Example

Applied Perioperative Practice Case Study of Non-Scheduled Perioperative Care Introduction Perioperative care is an integral component of overall surgical case management. It is created to address major problems relating to medical perioperative evaluation and postoperative care, particularly for high-risk patient.(Magallanes, 2002). Perioperative refers to the total surgical experience and includes pre, intra and postoperative phases of patients' surgical journey. (Phillips, 2004). The perioperative period is from the minute the patient arrives in through the operating theatre doors to the moment they leave through those same doors post-procedure. The objective of this study is to evaluate the perioperative care of non-scheduled cases. This includes the study of applied perioperative care in abdominal aortic aneurysm (AAA) in patient with coronary heart disease. It will prove the success of perioperative care in both the non-scheduled and elective surgery. It will describe the interaction of the patient with the perioperative staff and nurses through out the procedure. Overview A Perioperative medicine addresses the medical care of the surgical patient and focuses on the patient's status before, during and after the actual surgical procedure. Perioperative medicince is not a sub specialty of medicine but rather a body of medical knowledge that enables physicians to manage medical illness during the perioperative period, assesses operative risk, and respond to complications. (Magallanes, 2002). Perioperative surgery is classified according to the severity of the situations or case; the elective and the emergency surgery. In the elective surgery a patient were prepared for the procedure and is scheduled and is given a certain time of waiting not unless the case becomes severe. The emergency surgery is the one that needs to be done right away. It maybe an accident or a result of trauma. The injury maybe life threatening and therefore procedure will be done within 1-2 hours from admission. In this case it is important that the perioperative team will coordinate to each other in order to deliver safe patient care during the potentially traumatic situation the patient is into. The perioperative procedure was able to identify the risk during the phases of both the elective and the emergency cases, thus they will able to prevent the said risks. Because of its positive result and widely accepted the procedure is much appreciated by the surgeons, anesthesiologist, internist, nurses and even other healthcare staff involve in the procedure. According to Magallanes from an old study the clinical significance of perioperative medical care showed an approximately 80% of postoperative deaths on the surgical service were attributable to underlying medical conditions, whereas the 20% of the deaths were due to surgery or anesthesia.(Magallanes, 2002). A major benefit of having a dedicated perioperative service is the focus of improving and providing a better health service for patient. Critical Evaluation of the Incident In this case study the patient will be treated because of the sudden deterioration of the health of the patient. Consideration on her case must be done since she is 7 months pregnant. Evaluation of the procedure should be done carefully to avoid immature labor. Anesthesia and other medication should be properly computed and addressed to. Information to patients relative should be given to avoid confusion and other question.. The purpose is to cure the patient without endangering the baby on her womb and to be able to treat the mother successfully. This is a case of a 23 year old female patient, weighing 60 kg, with 7 months amenorrhea, with Kock's spine at level D4-D5 with paraplegia, was posted for anterolateral decompression as a semi emergency operation. Amenorhhea is the abnormal absent of menstruation.(Medline Plus, 2005). Patient complained of back pain since 6 months; followed by weakness of both lower limbs and inability to walk since 7 days. There was the past history of anorexia and night sweats since 5-6 months. There was no past history of cough, giddiness, trauma over back, convulsions, bowel and bladder involvement. Patient was on antituberculous treatment- isoniazid, ethembutol, pyrazinamide and rifampicin since one week ago. The antituberculosis drug mentioned above has no harmful effect in pregnant woman.(British National Formulary, 2006). The Patient was fully conscious, moderately built and nourished. Pulse, blood pressure, temperature and respiratory rate is normal. Patient was pale and there was no pedal edema. Local examination of back and spine tenderness in D4-D5 region, no swelling/ crepitus. On systemic examination respiratory and cardiovascular system were normal. Central nervous system examination- Hypotonia- below, D6 levels with paraplegia and normal power in both upper limbs. Deep tendon reflexes. Absent in both lower limbs and present in both upper limbs. Per abdomen examination showed- Uterofundal height - 28 weeks, fetal heart sound (F.H.S.)- 140bpm, regular, positioned left occipitoanterior (L.O.A.). Laboratory tests and other clinical consideration shows the following result; hemoglobin - 9.5 gms% ,other hematological, renal and liver function test, serum electrolytes etc. were normal. X-ray spine (A.P. View) - destruction of D4 vertebrae, osteomylitis of D4, paravertebral abcess or myeloma. CT scan (thorax) shows suggestive of osteolytic lesion of lower of D3-D4, Koch's lesion. Pre-anesthetics check-up was done. Patient was categorized to ASA grade III and written consent of risk of premature labor was obtain . ASA or the American Society of Anesthesiologist evaluates the case of the patient before choosing a certain procedure and anesthesia as to its morbidity and mortality. ASA Grade III means that a severe systemic disease is to be treated and it limits it's activity but is not incapacitating. The mortality rate of this grade is 4.5%.(surgical-tutor, 2006). The patient was given an oral diazepam 10mg for peri-operative procedure the other night. The general anesthesia was planned and the aims of the anesthetic management were as follows: 1. To avoid hypotension and hypoxia intraoperatively. 2. To maintain maternal and fetal oxygen delivery. 3. To avoid drugs that crosses the placental barrier 4. To avoid premature labour. Anesthesiologist doctor Dr.R.L. Doctor and Dr. Vakpil suggest the following procedure in inducing the anesthesia. Premedication of glycopyrrolate 0.004 mgKg -1, pentazocine 0.3mgKg-1, phenergan 0.25mgKg -1 was given intramuscularly 30 minutes before surgery. Diazepam 0.06mg/kg was given intravenously 10 minutes before the induction. Glycopyrrolate reduces salivary secretions. When given intravenously it produces less tachycardia than atropine. Pentazocine is used for moderate and severe pain. It depress neonatal respiration; withdrawal effects in neonates of dependent mothers; gastric stasis and risk of inhalation pneumonia in mother during labour..Promethazine is used for sedation. It has no evidence of tetragenocity. Diazepam is given as premedication; sedation with amnesia, and in conjunction with local anaesthesia. Diazepam is given with care, since it has risk in neonatal withdrawal. An intravenous line with 18g cannula was established. During induction the patient was kept in supine positionwith 150 left lateral tilt with the help of a wedge. Patient was preoxygenated with 100% oxygen for 3 min. Induction was done with thiopentone sodium 5mg/kg, followed by suxamethonium 1.5mgkg, administered intravenously to facilitate endotracheal intubation with proper sized cuffed endotracheal tube (ETT), applying "Sellicks maneuvers, the tube was fixed after confirming bilateral air entry. Thiopentone sodium it is short duration anesthesia ; reduction of raised intracranial pressure if ventilation controlled. Thipentone status as anesthesia is epilepticus. Such epilepticus are being neutralize by the administration of diazepam. Intravenous diazepam is effective but it is associated with a high risk of thrombophlebitis (reduced by using an emulsion formulation). Suxamethonium produces a muscle relaxation, it has rapid onset in a short duration. Sellick's maneuver is a method of preventing regurgitation of an anesthesized patient during endotracheal intubation by applying pressure to the cricoid cartilage. The above dose of anesthesia are base on the standard given by the British National Formulary. Maintenance of anesthesia was done with oxygen (50%), nitrous oxide (50%), pancuronium bromide, halothane in trace concentrations with controlled ventilation. Oxygen is prescribed for hypoxaemic patients to increase alveolar oxygen tension and decrease the work of breathing necessary to maintain a given arterial oxygen tension. Nitrous oxide depresses neonatal respiration. Pancuronium bromide a muscle relaxation (long duration) for surgery or during intensive care. Halothane is a volatile liquid anaesthetic. Its advantages are that it is potent, induction is smooth, the vapour is non-irritant, pleasant to inhale, and seldom induces coughing or breath-holding. On exploration through left thoracotomy paravertral abcess was found at D4 level and thoracic was performed. At the end of 2 hours and 55 minutes of surgery neuromuscular blockade was reversed with neostigmine 0.04mgkg and atropine sulfate 0.01mgkg intravenously. Neostigmine has no clinical effect on the pregnant women. Atropine sulfate has no harmful effect to the patient and the mother. Postoperatively, patient was monitored for first 24 hours in the surgical intensive care unit. Oxygenation was done with ventimask with flow of 2-3 liters. Fetal heart rate monitoring was also done, analgesics, antibiotics were given. No tocolytics agents were advised by the obstetrician for prevention of premature labor. Patient developed mild pregnancy induced hypertension in the later part of pregnancy and was treated. After 2 months a male baby with 2.2 Kg BW with APGAR score of 8, was delivered with help of outlet forceps under pudendal nerve block. On the delivery the patient anti-hypertensive where stopped and on post delivery day patient was discharged. Pudendal nerve block is a regional anesthesia resulting from the use of a local anesthesia to deaden the pudendal nerve in the region of vulva and labia majora. It is used to lessen the discomfort during childbirth. The common non-obstetric surgeries during pregnancy are ovarian cyst, appendectomy and others. Regional anesthesia with local anesthesia are used in this case because of its low incidence of abortion. The patient being treated in this case is pregnant but need an immediate operation because of her worsening situation. The patient used the following inhalation because of its effect both in the mother and the neonate. Nitrous oxide maternal effects: low blood solubility of nitrous oxide renders uptake and recovery very rapid. Although its analgesic effects are good, its low potency does not provide complete analgesia for delivery. Nitrous oxide administered in analgesic concentrations (50-75%) does not cause maternal cardiovascular or respiratory depression and does not affect uterine contractility. In neonatal the effects are: respiratory depression and fetal acidosis occur after long administration, especially if maternal analgesia is incomplete and maternal catecholamines are elevated. Halogenated agent such as halothane has the following effect: Maternal effects: in anesthetic concentrations, all halogenated agents cause cardiovascular and respiratory depression. Uterine activity decreases in a dose-related fashion. In low concentrations, 0.4-0.8%, these agents are used to prevent maternal awareness during general anesthesia for cesarean section. When uterine relaxation is needed (entrapment of the second twin, the fetal head, retained placenta), rapid uterine relaxation is provided by hyperventilation of the mother under general, endotracheal anesthesia with high concentrations of these agents. Intravenous oxytocin is needed to reverse uterine relaxation after washout of the inhalational agent. Danger: maternal hyperventilation with high concentrations of a halogenated agent may result in cardiovascular collapse from cardiac depression. Fetal effects: low concentrations over a short period of time cause neonatal sedation. Higher concentrations and prolonged administration result in neonatal apnea and hypotension. (A.M. Faura). In 1961, Sellick (from the name of the procedure derived) demonstrated that occlusion of the esophagus by cricoid pressure in cadavers prevented flow of barium from the stomach to the pharynx. He reported successful use of this technique in 26 'full stomach' cases - intestinal obstruction, gastrectomy for pyloric stenosis, and forceps delivery. In three cases, the pharynx filled with gastric contents when cricoid pressure was released after inflation of the tracheal tube cuff. He advocated passage of a gastric tube to empty the stomach. He described, with illustrations, precisely how cricoid pressure should be applied. Sellick's maneuver changed the management of anesthesia worldwide. (Malby,Beriault, 2002). Usually pregnant women with tuberculosis during pregnancy bears a low weight baby. Antituberculosis medication has no specific effect on the baby. Treatment should not be delayed for pregnant women who have TB disease; rather, it should begin as soon as TB is diagnosed. The preferred initial regimen for pregnant women who have TB is isoniazid, rifampin, and ethambutol for at least 9 months. In most cases, pyrazinamide should NOT be used because there is not enough information about how this drug affects the fetus. Streptomycin should NOT be used because it has been shown to have harmful effects on the fetus. In this case pyrazinamide was used but this does not affect the pregnancy of the patient. Cephalosporins, crosses the placental barrier, but no embryological or fetal effect are observed. These drugs were used in our patient: Tramadol 50mg cap twice a day was given orally as an analgesic in the immediate postoperative period, which has no/less side effects. In late pregnancy the fetal circulation plays an important role in the distribution of drugs transferred within the infant. Minimization of the autonomic hyper flexia. Autonomic hyper flexia is common in lesions T4-T5 levels, which is characterized by throbbing, headache, facial flushing and paroxysmal hypertension, which should be treated immediately. Epidural or spinal analgesia can be given to attenuate the hypertension is questionable due to high incidence of adverse reactions. Our patient on this study has been recovering very well. From the time of her admission until the time of discharge she has been handled well in the hospital. No complications and other effects were noted since proper calculations of anesthesia as well consideration of her situation were done. Her family and relatives are with her though out the procedure. The family support also helps the patient to recover fast. Her baby was delivered with no side effects or bad effects of the anesthesia and medication given to her. Test for the baby were done upon delivery to ensure that the baby is safe. The baby weighs below the normal size of the baby. He weighs only 4.23 lbs. normal in length and no significant effect on the color of the baby. The mother as well is recovering from the operation and from the delivery of the baby. The mother can now sit and walk. She was able to eat and drink well. The bowel movement is normal and it seems that there is no worry in the operation. Before she will be discharge instruction on the medication were given. A post op check will be done after a week. Counseling were done to release the trauma she had been thru during the operation. The patient can have her counseling even when she is at home. Follow-up on the baby is also done to ensure that there is no bad effect on the system of the baby. The tuberculosis of the mother is treated until the 6 month. X-ray and other test will be done before ruling out that the mother is now free of tuberculosis. Her medication for tuberculosis continued except for pyrazinamide which is given only within 2 months of medications. The suture is recovering and no adverse effect seen on the sight of the operation. Conclusion I therefore conclude that the perioperative care in a patient is effective in all aspect. In order for the patient to recover from a traumatic surgery would include the help of the patient, family hospital staff and doctors. It is important to follow a pathway in order to provide a better service. From the time of admission up to the time of discharge and up to the patient at home. Proper understanding of the patient situation should be done before pursuing a procedure. Taking consideration of the history of the patient before the operation is important. The patient must be prepared not only physically but also psychological. The other professionals involved in this case has helped to make the case successful. Other side effects were prevented and prevented because of the proper knowledge of the case. The perioperative care is now successful worldwide because of its positive outcome specially in a surgical cases. Continue study is on its way to developed an innovative patient care worldwide. The government has provide guidelines for the patient care and they are making all things possible because of their cooperation and other organization. Proper acknowledgement and study should be done to be able to produce a better healthcare. Reference 1. Operating Room Technique, 10th edition , Philips, N. (2004) Berny and Kohn's, St. Louis, Mosby 2. Perioperative Care In Nursing the Surgical Patient, Smith,D. (2000), Pudner, R., 1st Edition Edinburgh: BAilliere Tndall. 3. The Perioperative Medicine Service: An Innovative Practice at Kaiser Bellflower Medical Center; Marcus Magallanes, The Permanente Journal 2002, Volume 6, No.3 4. Anesthetic Management of Paraplegic Patient with Pregnancy for Spine Surgery, Dr. T.D. Doctor, Dr. S. D. Vakil, 2003, 47. 5. Assessment of Fitness for Anesthesia and Surgery Copyright 1997-2006 6. Module 4, Treatment of TB Infection and Disease, page 14. 7. Anesthesia For The Pregnant Patient, Evaline A.M. Faure, 8. Science Pseudoscience and Sellick/Science, Pseudoscience et Sellick, J Roger Malby, Michael Beriault, 2002. http://www.cja-jca.org/cgi/content/full/49/5/443 Read More