Smoking history - Essay Example

Introduction General Anaesthesia provision can be complicated for a patient having smoking history. This is a case of a female patient going to takeanaesthesia with history of smoking. Due to the changes in physiology as compared to a normal patient, it is important to focus on the health risks involved in anaesthesia for a smoker. Cigarette smoke contains harmful toxic materials like alcohol, nicotine, tar, phenols, tar and hydrocarbons (Drain, 1994 pg 527). A complete examination and assessment of general health and airway positioning is done before suggesting anaesthesia. Case Summary Linda is a 32 years old female, who is admitted in emergency after 2 days of urinary problems/infection. She holds a history of 18 years of smoking. She is asked to stop smoking immediately and operation is suggested to be done after a few weeks. Linda is scheduled to undergo a urethral dilation and curettage in addition to Hysteroscopy and laparoscopy. 1. Operative assessment Smoking history increases the risk factor in the whole process and the number of complications may increase at postoperative stage. “The ratio of smoking addicts is 40-50%, they are moving towards death because they continue smoking” (Nel & Morgan, 1996). In smoker’s body, the demand of oxygen is greater; the carbon monoxide in cigarette binds with the haemoglobin in the blood to form carboxyhemoglobin and it reduces the supply f oxygen to the tissues by 15% or more, which results in a supply demand imbalance (Amoroso 1996).It is assessed that the anaesthesia procedure is effected by the imbalance caused by carboxyhaemoglobin, it occurs right at the time when oxygen demand is higher in anaesthesia. Surgical diagnosis/proposed operation It is specially considered that the reliability of assessment methods is considered. It is due to the fact that a standard preoperative monitoring method, pulse oximetry, is not capable to identify carboxyhaemoglobin, as it only identifies haemoglobin and oxyhaemoglobin. The other negative point according to Taylor & Goldhill (1992) is, ‘pulse oximeter overestimates the patient’s oxygen saturation, and consequently decreased oxygen saturation is not detected straightaway’. During preoperative stage, there are chances of going through adverse cardiovascular for Linda. Nel and Morgan (1996 p.309) point out, ‘Smoking is also a major risk factor for arterial thromboembolism and coronary vasospasm by multiple pathways including direct endothelial damage and haematological, metabolic and biochemical disturbance’. Urethral dilation and curettage in addition to Hysteroscopy and laparoscopy is scheduled to be done. General condition/age/sex/weight Linda is a 32 years old female, working in a local library. She is 89 KG, 5 feet and 8 inches and her BMI is 32.9 cm/m^2. Vital signs were blood pressure 124/79, 19 respiratory rate and 98.7 F body temperature. She lives with her family and smoke 18 to 20 cigarettes daily on an average. She is occasional alcoholic as well. She was admitted to the hospital in the evening and observed to have anxiety symptoms and looked depressed. It is may be due to the fact that she has never undergone any surgical procedure. She is briefed about anaesthesia and advised to stop smoking to avoid complications and further problems. Linda is allergic to dust, hot foods and dairy products as well. She had Mallampati score 2 and thyromental space is 6.1cm with full neck movement which shows no or little difficulty in airway management. Preoperative tests were cell counts, considering her smoking history haemoglobin status is checked in addition to cardiovascular and respiratory tests. It is planned for Linda to undergo a urethral dilation and curettage in addition to Laparoscopy and Hysteroscopy. Past medical history Linda has never undergone any surgery. She used to take some pain killers and pills for skin allergy sometimes. Her overall health was not very bad despite her smoking habits. Medications and allergies No medication except some vitamin pills. Linda is allergic to dust, dairy products, hot foods and beverages. Smoking/alcohol history Linda is an anxiety patient and her gastric acidity is increased. Her smoking habits affected the cardiovascular, immune, gastrointestinal and respiratory systems. As she has got higher airway hyperactivity, there are the chances of preoperative pulmonary complications as well. It is considered that there can be the need of pulmonary tests and consequently the treatment if the need may be. Cough, haemoptysis and short breath can be the symptoms in this regard. Pre-operative mental state of the patient Linda is afraid of anaesthesia and surgical procedure as she has never experienced it before. Her anxiety level is high as the intake of smoke is stopped. So, overall she is not relaxed and requires counselling. She is already encouraged to stop smoking and keep herself relaxed. She will be calm down and will be given a briefing about the procedure and expected complications before surgery. Significant findings on examination The Linda is adversely affected by smoking, her respiratory system is damaged which can further complicate anaesthesia. Cilia is destroyed which has increased the mucous secretion in airways. Woerlee (1988) points out, ‘The trachea, larynx and bronchus are particularly affected –increasing the chance of laryngospasm and bronchospasm on both induction and emergence from anaesthesia. It is also emphasized by Amoroso (1996 p.89) that the smaller airways, narrowing, reduced pulmonary surfactant and compliance means less oxygen, exchange and a tendency for a ventilation-perfusion mismatch. Results of abnormal or relevant normal pre-operative investigations Main objective of the premedication is to reduce the anxiety level, which was present in Linda. Anxiolytic medication can be useful, for example, benzodiazepine (Avidan et al. 2002). Some precautions were adopted in order to avoid the risk of gastric contents into lungs, whish is a fatal complication. Linda is been having fast for 8-10 hours before surgery. She had clear fluid intake before the scheduled time of operation. Considering he smoking history, non-particular antacids, histamine receptors blockers and proton pump inhibitors are also considered before he induction of anaesthesia (Avidan et al. 2002), they also explain that Metoelopramide and erythromycin encourage gastric emptying. Irrespective of the precautionary measure taken, patients remain at the risk of aspiration. To summarize the problems this patient has with anaesthesia, I would say that Linda is just scared and have a higher anxiety level. 2. The Conduction of Anaesthesia Anaesthesia conduction may cause adverse affects for smoker patient, for example, coughing and breath holding (Dennis et al. 1994); it will cause decreased oxygen saturation and lesser airway clearance. Nel and Morgan (1996 p. 128) explain that potential postoperative pulmonary complications include atelectasis and pneumonia and patients having smoking history are frequent victims and also cause morbidity in such patients. It is also considered if there are some adverse affects on Linda’s immune systems. Immune system impairment can cause harm to the surgery procedure, there is a chance of increased wound at one hand and on the other hand the healing process may decrease. ‘The immune system is affected by cigarette smoking; aspects of the immune response including reductions in neurophil activity, in immunoglobulin concentrations and natural killer cell activity are influenced’. Nel and Morgan also argue (1996 pg.310) that the impaired wound healing is may be due to the toxins in smoke which decrease oxygen pumping in the whole body. One of the most important and major aesthetic implication for a patient like Linda can be the decreased immune system receptiveness and increased chances of postoperative respiratory tract infections (Nimmo & Smith 1989). Pre-medication Considering Linda’s history and condition there can be increased metabolism for drugs which occurs as a result of increase in hepatic enzyme secretion due to smoke. This increased metabolism influences the dosage requirements of drugs to be administrated; in particular analgesia requirements may need to be increased (Stoelting et al. 1988). Linda is may be having risk of aspiration of gastric contents; it is due to the smoke which delays gastric emptying and increased gastric acidity. According to Lichtor (1990 p.106), there is a strong association between smoking, anxiety and increased gastric acidity, when smoker is anxious, he/she smokes more creating a vicious circle in relation to gastric acidity. It holds great anaesthesia implications which are considered in Linda’s case. Clinical assessment of airway is done, ‘Mallampati scoring system the patient sits opposite to anaesthetist with mouth open and tongue protruded’ (Colin et al. 1999 p.3).According to Colin and other (1999) ‘if the thyromental distance with the neck extended is less than 6.5 cm or the width of three fingers, difficult intubations is predicted. A thyromental distance of less than 6.5 cm and Mallampati class 3 or 4(Only soft palate is visible/not visible) predicts 80% of difficult intubations’. The patient under consideration falls in class 2 of Mallampati score with faucal pillars and soft palate with visible uvula. Thyromental distance is 6.1 which indicate no difficulty so far. For Linda normal endotracheal tube was selected. Wilson risk assessment is done to get further predictive airway information. At Wilson risk factor score > 2 predicts 75% of difficult intubations, also with high incidence of false positives. Wilson risk factors are; obesity, restricted head/neck or jaw movement, receding mandible or buck teeth’ (Colin et al. 1999 p.3).On assessment Linda was found to have 2 point at Wilson’s risk factor. Airway evaluation: she can have difficulty during surgery due to coughing because of her acute smoking habits. Linda is briefed about the anaesthesia and the operation procedure. A friendly way is adopted to keep her anxiety level down so that the fear for operation will be lessened. It is made sure that she is given 6L/min oxygen via Hudson mask before anaesthetic, in order to saturate and fill lungs with oxygen as much as possible. During preoperative stage Linda’s vital signs were monitored by using 3 lead ECG. Chest x-ray is conducted; patient was having normal heart beat and lungs condition. Blood test is done to check the normal level of salt in blood, blood clotting, bleeding and kidney function. Her complete general health assessment is done in addition to blood pressure 124/79 mmHg and oxygen saturation monitored at 95%.It is considered that low oxygen level can be more down due to her smoking history and presence of carboxyhaemoglobin in blood. In pre-operative period, after complete check-up of her allergies, blood pressure and pulse rate, almost 2ml Procaine is administrated. Drip is also set on hydration rate considering the pre-operation fasting of few hours. With a local anaesthetic, Procaine 1000 ml Hartmann’s is also administrated through pump giving set. It is used for Linda because of her non-allergic condition to chemicals. Benzodiazepine is also considered for pre-medication. The whole process is again briefed to Linda and she is comforted in order to feel relaxed and prepared for the surgery. Aesthetic technique/drugs/reason for choice Observing Linda’s airways and vital signs, 3 mg of Midazolam is administrated to Linda in the beginning. It was given in order to decrease the stress level and anxiety. It has a great impact on Linda, leaving her less anxious and in a light doze (Drain 1994).It is considered better to use local aesthetic with regional aesthetic which results in better outcome in order to maintain patient’s comfort. ‘The simple administration of sterile intravenous crystalloids like normal saline and Hartman’s, has allowed an extended the surgical repertoire. In this process blood and fluid loss is replaced during surgery or during postoperative period, as, without the safe transfusion of blood and blood products many major surgical procedures can not be undertake’(Avidan et al. 2002). Induction/maintenance/analgesia/muscle relaxation/reversal At the time of aesthetic induction oxygen supply of Linda was shifted to a black mask which is connected to a Bains circuit. Propofol and Procaine are combined to work as induction agent. ‘Propofol is selected as induction agent because of its affect in combination with Midazolam, without much effect on central nervous system. Addition of Procaine was done to avoid the sting sensation at the time of Propofol induction. For muscle relaxation, Ataracurium, muscle relaxant was used which is a non –depolarising agent (Drain 1994).Ventilation was started manually and saturation increased to 99%.Vital signs seemed stable and to maintain anaesthesia, Nitrous Oxide and Isoflurance were used. Airway control/breathing system/mode of ventilation In order to let muscle relaxant work completely, after four minutes of ventilation Linda was incubated to get maximum level of oxygenation. Endotracheal tube of standard diameter is passed through vocal cords easily. Observing the stable vital signs of Linda, tube was reviewed for any leak and eyes were protected from any irritation. Monitoring employed Linda was shifted to operating table in a lithotomy position and with that monitoring was also reconnected. During the surgery Intravenous fluids (IV) were continuously regulated and monitored. Vital signs are more or less stable and muscle relaxant was used successfully. Operative procedure performed During surgery Linda was continuously been ventilated by machine and anaesthetic was used with the infusion of Oxygen, Isoflurane, nitrogen oxide and Atarasurium which were turned off after the completion of treatment and eye covering removed. A muscle relaxant, Neostigmine, in combination with Glycopytrelate is also administrated; it combats the effects of Neostigmine and smoothes the process of reversal (Drain 1994).Linda seemed relaxed after surgery and she started breathing independently. Before extubation, a large amount of secretions were removed from the airway by using a Yankeur sucker. At the end Linda took a deep breath and the tube was removed as she exhaled .Suction was completely done to increase the oxygenation, for this purpose oxygen is provided by black mask. Linda was normal in 10 minutes and she was thoroughly observed for further signs of any complication. She was taken to the recovery in a proper manner and 1m/L oxygen is administrated to her, before that a proper airway was also maintained by the jaw tilt. Duration/complications/blood loss The whole surgery took about 30 minutes and everything went smooth without any complication as blood is replaced during surgery. Her surgical incisions were observed for bleeding and swelling. Fluid given in theatre During the surgery and after surgery Intravenous fluids (IV) were continuously regulated. According to SBMJ (2007 p.131), “A fluid challenge is often used both to assess and treat volume depletion, particularly in actually ill patients. Central venous pressure should be monitored continuously; it helps fluid administration, for example, more fluid is required if the central venous pressure falls after rising.” Hypertonic saline is considered because it can move fluids from extra vascular space and drawing fluids in the circulation across a sodium gradient (SBMJ 2007). 3. Post operative Care Every patient who had an operation under either regional or general anaesthesia is in a potentially unstable cardiorespiratory state, according to Jonathan M Behar and colleagues of Royal college of Anaesthetics. Linda is thoroughly checked for blood pressure, oxygen saturation, heart rate and rhythm and also the consciousness level. She was asked if she can feel any pain after reorientation period. Upon her unrest and pain in surgical areas she was relieved. It was ensured before the transfer to ward that; She is maintaining a secure airway independently with intact airway reflexes and independently breathing with enough oxygen saturation. Linda was haemodynamically stable and analgesia was prescribed. Treatments for controlling post-operative pain are; intramuscular, subcutaneous, oral, intravenous, rectal, transdermal and transmuscular analgesia; continuous infusions of opioids and /or NSAIDS; patient-controlled administration of opiods and/or NSAIDS; and intermittent boluses and/or continuous infusion of epidural or intrathecal opioids (DiNicola, N. &, Thompson 2004). Epidural analgesia is used for Linda as; it was to provide superior pain relief considering her first surgery and the affectivity level. DiNicola, N. &, Thompson suggest, “Epidural analgesia is more useful technique for the relief of postoperative pain because a catheter can be used to maintain analgesia in the postoperative period.” Only doctors or specialised administrator can do “Top Up” by programmed pump”. To help avoiding fluctuation levels in analgesia, drug is infused through a pump. Describe the sequence of events in the recovery area Recovery room was kept warm and properly lit. It was near Operation Theatre and completely monitored for any kind of emergency. Linda was a little disoriented and in pain. She was given pain relief and comforted by warm blankets. A nurse there had friendly conversation about the procedure and prepared her for further precautions. She was asked to take care of the incisions and the area should be kept cleaned and support should be provided by neat pad. It was understood by her that bleeding will stop in a few days. As Gwinnutt (2004), ‘A patient who cannot maintain his/her own airway should never be left alone’. So, Linda was not left alone as she had some cough after surgery. Linda was checked thoroughly, she was completely conscious and comfortable in maintaining airway. She was not drowsy anymore and breathing independently. She had stable cardiovascular system and bleeding was not unbearable from the surgical incision. After surgical procedure closed, anaesthesia was terminated and little amount of fentanyl was titrated to respiratory and Linda was again in senses. She was warm and pain was relived before her discharge. According to Gwinnutt (2004 p.72) the length of time a patient spends in recovery depends on many factors; it can be length and type of surgery, aesthetic surgery and the number and extent of complications. As it is agreed by the policy of hospital, patient is to be holding at least 30 minutes in the recovery; Linda stayed 30 minutes in the recovery and taken best attention possible. When the patient is transferred from Operation Theatre to recovery, proper supervision is provided to avoiding any kind of potential trauma like hypoxia or accidental disconnection of drains (Avidan et al. 2002). She was haemodynamically stable, pain and nausea was controlled. Hypoxemia is a respiratory complication this kind of surgery. It has the possibility to start after three days of surgery. According to Avidan and others (2002) there is a chance of Cyanosis which is very insensitive, Linda is specially observed for such complications. On diagnosis, due to her smoking history, it is diagnosed that lighter Hypoxemia chances are there for Linda. It is indicated that the saturation level of patient will be 85%, which was 97% until postoperative period. Gwinnutt (2004) suggests , “If Hypoxemia is severe, persistent or when there is any doubt, arterial blood gas analysis should be performed, it can be caused by a number of factors, be it alone or in combination; Alveolar hypoventilation, ventilation and perfusion mismatch within lungs, diffusion hypoxia, pulmonary diffusion defects and reduced inspired oxygen concentration”. Linda is considered to be a potential patient to be affected by ventilation and perfusion mismatch within lungs, because she is a smoker for over a period of more than ten years and also an occasional alcoholic. Most of the times in patients like her ventilation of the alveoli (V) and perfusion with blood is not mismatched (V/Q=I) according to Gwinnutt (2004 p.73), “it ensures that the haemoglobin in blood leaving the lungs is completely saturated with oxygen. During anaesthesia and recovery period, there is a possibility of this process disturbance. According to Gwinnutt (2004) areas develop where perfusion exceeds ventilation (V/Q, I), it results in haemoglobin with reduced oxygen content or vice versa; ventilation exceeds perfusion (V/Q>I) which is considered to be wasted ventilation. Blood is fully saturated at 98% and more oxygen will be of no use.” According to (Colin et al. 1999), ‘Patient’s fluid status may be affected by underlying disease process or by its treatments.’ Linda is out of danger from any such situation as; her blood oxygen saturation level is almost full at 97% at the time of discharge. Linda was feeling little pain and irritation in incision areas. It is considered due to the fact that most patients complaints about the discomfort. Discomfort or pain with swelling is also reported in some patients. According to Surgery Channel’s surgery information report (2001), ‘Patients may be asked to rate their pain on a 1-10 scale to determine the level of discomfort; slight pain is 1-2; annoying pain is 3-4; significant pain is 5-6, severe pain is 7-8 and excruciating pain is at the level of 9-10.Linda was asked to rate her pain on 1 to 10 scale level and she reported her pain at 1-2 level. So, it is considered that after pain relieving medication, the situation is under controlled. For avoiding muscle pain and relaxation, succinylcholine is used. Nigrovic and Wierda conclude in their research that administration of succinylcholine may lower the risk of muscle pain, after anaesthesia. Pattern and severity of pain Analgesia is a state when only relief of pain is provided. The regime adopted was successful both in opinion of aesthetic and patient after 48 hours of surgery. As discussed in (Cynthia 2006), “Longer and complicated procedures like revision arthroplasty, acetabular and bone grafting wit the risk of injury to pelvic structures and insertion of long stem femoral prosthesis that are associated with major blood loss and fluid shifts are suitable procedures for integrated EGA”. Aesthetic is used in combination with muscle relaxant which actually helped surgery to be performed. “Post operative epidural analgesia may significantly reduce the time until extubation and need for mechanical ventilation after major abdominal or thoracic surgery” (Edward et al. 2001). Linda was comfortable and not scared unlike her preoperative period. She was having a strong craving for smoking but it was asked not to start it again as it will help in keep her healthy. It was ensured that her successful surgery was due to the fact that she left smoking in preoperative period as prescribed. She has unrest in her throat and couldn’t remember about the surgery exactly, due to the drug. Conclusion Linda was normal after 48 hours of aesthetic surgery. She properly followed and cooperated with medical staff and thus, had a smooth and normal surgery without any complication. Linda had potential for impaired surgical wound healing, she is advised to maintain clean environment around wounds. If followed properly, it will not only promote less complication but also accelerate healing of wounds. Low anxiety levels after counselling helped in taking drugs affect properly. She seemed satisfied with the operation and her wound management. She had a desire to stop smoking for ever, which is the best part. Read More