Care of Patient Undergoing General Anesthesia - Case Study Example

Introduction As an anesthesia assistant, this writer comes across patients undergoing surgical operations in practice. However, in practice, anesthesia is mandatory before any surgical procedure, and it must follow strict safety precautions and attendance to details of an anesthesia protocols indicated for any particular procedure (May et al., 2007). As an assistant, this writer has to carry out different parts of the whole procedure of anesthesia where safe transit of the patient from preoperative state to postoperative reversal is the goal, while the surgical team performs the surgery. In this assignment a case study approach has been taken to identify different anesthesia related activities and their rationale which will be corroborated to examine whether these activities are based on evidence from scientific literature on anesthesia. This is a case of a 40-year-old female who had been admitted for undergoing laparoscopic cholecystectomy to the hospital. It was decided that the patient will under the surgery undergo the surgery under general anesthesia. This patient was found to be having no associated medical disease, and the preoperative investigations revealed that she has optimal medical condition to undergo anesthesia. Since anesthesia and elective operations should not proceed until the patient is in optimal medical condition, through the preoperative medical tests it had been demonstrated that she has no significant perioperative risks, it was decided that it would be safe to proceed (Adams et al., 1998). Selection of Safe Anesthetic Equipment In the operating room, before subjecting the patient to anesthesia, all the equipments must be tested for safety in that they are in the right condition of use. The anesthetic assistant is supposed to help the anesthesiologist in the operating room in major cases, and he hardly has time to check these in the equipment supplied. Therefore, one of the important roles of the anesthetic assistant to check and make sure that the equipments used for anesthesia are in a condition, where no catastrophe will happen (May et al., 2007). In inhalational anesthesia, a oxygen and nitrous oxide mixture is inhaled. Liquid oxygen storage temperature must be checked. The only reliable way to determine residual volume of nitrous oxide is to weigh the cylinder. The assistant must record those. The pin index safety system must be examined. The role of the assistant is to check medical gas systems thoroughly so medical gas depletion or supply line misconnection is detected or prevented. It is also important to arrange an emergency supply of oxygen in the operating room. Oxygen cylinder pressure should be monitored before use and periodically during use (Ehrenwerth and Eisenkraft, 1993). Breathing circuits link a patient to an anesthesia machine. The devices can be fitted with connections and equipment that allow intermittent positive-pressure ventilation (IPPV) and passive scavenging, as well as continuous positive airway pressure (CPAP) and positive end-expiratory pressure (PEEP). These are systems based on connections, and the assistant must check whether all the connections are leak proof or not. Misuse of anesthesia gas delivery equipment is three times more common than equipment failure in causing equipment-related adverse outcomes. Lack of familiarity with the equipment and a failure to check machine function are the most frequent causes (Rosenblatt, 2001). Whereas the oxygen supply can pass directly to its flow control valve, nitrous oxide, air, and other gases must first pass through safety devices before reaching their respective flow control valves. A rise in airway pressure may signal worsening pulmonary compliance, an increase in tidal volume, or an obstruction in the breathing circuit, tracheal tube, or the patient's airway. A drop in pressure may indicate an improvement in compliance, a decrease in tidal volume, or a leak in the circuit. The assistant must monitor these and warn the anesthesiology against a failure (Langeron et al., 2002). Whenever a ventilator is used, "disconnect alarms" must be passively activated. Anesthesia workstations should have at least three disconnect alarms: low pressure, low exhaled tidal volume, and low exhaled carbon dioxide. It must be checked whether these alarms are working or not. Large discrepancies between the set and actual tidal volume are often observed in the operating room during volume-controlled ventilation. Causes include breathing circuit compliance, gas compression, ventilator-fresh gas flow coupling, and leaks in the anesthesia machine, the breathing circuit, or the patient's airway. Therefore during monitoring, the assistant must be vigilant about these changes. A routine inspection of anesthesia equipment before each use increases operator familiarity and confirms proper functioning. There should be a generic checkout procedure for anesthesia gas machines and breathing systems (Dorsh and Dorsh 1999). Equipment misuse is characterized as errors in preparation, maintenance, or deployment of a device. Preventable anesthetic mishaps are frequently traced to a lack of familiarity with the equipment and a failure to check machine function. Flow meters are calibrated for specific gases. Causes of flow meter malfunction include dirt in the flow tube, vertical tube misalignment, and sticking or concealment of a float at the top of a tube. For assistants adequate training about the machine is mandatory to be able to check safety. Frank disconnections occur most frequently between the right-angle connector and the tracheal tube, whereas leaks are most commonly traced to the base plate of the CO2 absorber. In the intubated patient, leaks often occur in the trachea around an uncuffed tracheal tube or an inadequately filled cuff. Every addition to the breathing circuit, such as a humidifier, increases the likelihood of a leak. Any connection within the breathing circuit is a potential site of a gas leak. A quick survey of the circuit may reveal a loosely attached breathing tube or a cracked oxygen analyzer adaptor. Less obvious causes include detachment of the tubing used by the disconnect alarm to monitor circuit pressures, an open APL valve, or an improperly adjusted scavenging unit. Leaks can usually be identified audibly or by applying a soap solution to suspect connections and looking for bubble formation. Leaks within the anesthesia machine and breathing circuit are usually detectable if the machine and circuit have undergone an established checkout procedure (Caplan et al., 1997). This author’s role in this case was to ensure appropriateness of all the equipments that would be necessary and to ensure safety. The equipments of intubation were checked, and they were provided to the anesthesiologist in the appropriate time and stage of anesthesia. Moreover, one of the main important roles is attachment and observation of all monitoring devices during the surgery. The vascular access and maintenance will also be the assistant’s role. Once the patient was positioned, the anesthetic level was kept in such a level that the patient will neither feel pain nor remember the operation. Yet this “anesthetic depth” must be balanced against the hemodynamic consequences of excess anesthetic, as well as the potential for delayed wake-up. The assistant must be able to gauge the level of anesthesia clinically and with instruments. The patient's heart rate and blood pressure, which should be neither high from sympathetic response to noxious stimulation, nor low from overdose with anesthetics. At the same time, the assistant monitors pulse oximetry, blood pressure, heart rate, ECG, tidal volume, respiratory rate and peak inspiratory pressure, inspired oxygen, the concentration of respired gases and vapors, and the capnogram (Jubran, 1999). The degree of muscle relaxation is monitored with the help of a nerve stimulator and by watching the operation and gauging muscle tone, which might impede the surgeon’s work. A tedious aspect of the work is the obligation to keep a record of all these events and of activities, such as the administration of drugs and fluids, adjustment of ventilator settings, and even of surgical events (Lake et al., 2001). Strict monitoring the apparatus and monitoring data and their adequate reporting to the anesthesiologist are important aspect of the job role. Moreover, this anesthetic assistant handed over all the other equipments such as laryngoscope, Magill forceps, roller gauge, connector, and tubing end to the anesthesiologist during the procedure (Kluger et al., 1999). The most important function that an anesthetic assistant may do is to apply cricoids pressure during intubation so there is no accidental intubation of the esophagus thus preventing a catastrophic event. Properly trained, a critical respiratory monitoring may help diagnose this, and the anesthetic assistant can draw the anesthesiologist’s attention to this (Meek et al., 1999). Anesthetic risks are usually smaller than the risks associated with surgical interventions, but they loom large when general anesthesia or heavy sedation is required for a non-invasive and essentially risk-free diagnostic examination. While it would be ideal for each patient to understand the details of his or her medical care and participate in all decisions, that level of true “informed consent” is unattainable. Patients will almost invariably be cared for by several experts. The patients are usually concerned about the episode of anesthesia and the surgery. Patient education is a vital component of the surgical experience. Preoperative patient education may be offered through conversation, discussion, the use of audiovisual aids, demonstrations, and return demonstrations. It is designed to help the patient understand the surgical experience to minimize anxiety and promote full recovery from surgery and anesthesia. These are important for the patients with optional surgical procedure. The assistant can assess the patient's knowledge base and use this information in developing a plan for an uneventful perioperative course (Shelly and Nightingale, 1999). In this assignment, I found that the academic training about the anesthetic assistant came in handy while delivering care to the patient. In fact, it began from the time when the patient was brought in to the operating room and was placed on the table. I greeted her, and she was obviously nervous. She was looking at the operating room very anxiously and around to the anesthesia machine and apparatus. I told her gently that these are the machines that would supply her oxygen and other gases to maintain her state of relaxation and painlessness. She was worried, and I explained in laymen’s terms as to what we are going to do. Before her entry I checked all the monitors and parts of the apparatus and equipment that would be necessary including the gas cylinders, tubings, bags, electrical connections, and other parts. I set up an IV line and attached the pulse oximetry adapter, ECG leads, and sphygmomanometer. These would be used to monitor different vital signs parameters. I also attached the airway monitors when the patient was induced. My role was to keep a vigilant eye while the surgery was going on. There was no indication for any adverse event, and the surgery went well. After the patient was reversed, I had to maintain her breathing as long as the respiratory parameters were stable enough to send her to the recovery unit. I was new, there were bound to be some errors, but one thing is important, all these functions must be practiced to master them (Smith and Rawling, 2008). While deciding the mode of anesthesia, the patient’s condition for which the surgery is being done is the most important consideration. The surgeon’s choice and the patient’s preferences next come in order. This is a case of laparoscopic cholecystectomy, and hence it needs instrumental manipulation of the upper abdomen without interfering with the respiratory drive of the patient. Adequate relaxation of the abdomen is the most important determinant of such surgeries. General anesthesia with intravenous and inhalational anesthetic agents where the process is augmented by nondepolarizing muscle relaxants would serve the purpose best, and given the patient’s age and status of her medical history, the safe and most convenient choice of general anesthesia was deployed. Once the preparations for general anesthesia were complete, the patient’s history and physical examination were reviewed, the machine and equipment were set up and tested, the patient is on the table, and the monitors were applied, the patient was ready to undergo general anesthesia. Injectable drugs were used to induce the anesthesia, and following intubation, through the endotracheal tube, inhalational agents were used to maintain the anesthesia. In order to achieve relaxation, when neuromuscular blocking agents were used, the ventilation ceased, and the ventilator system connected through the tubing took over the ventilation. The direct laryngoscope was used to visualize the larynx through which the endotracheal tube was placed in position. The patient was unconscious, and hence the connected monitors were indicating the different parameters of safety in terms of vital organ functions. Since there was no spontaneous breathing monitoring the status of oxygenation and cardiac functions were most important. During general anesthesia, we must provide the patient with sleep, amnesia, and analgesia; we must monitor his vital signs and keep them within physiologic limits, and we must make the surgeon’s task as easy as possible with the double benefit of helping the surgeon so that she can do her best for the patient. The intravenous line would serve as the conduit for administration of different drugs and fluid during the surgery (Smith and Rawling, 2008). The patient was asked about her concerns; she said she was worried that the sleep that is being induced in her may not be reversed. I explained her that these machines are sophisticated enough and checked repeatedly according to the safety protocols of the hospital, and there are doctors who will be monitoring and intervening her status continuously. There is no point to worry, and our system would be adequate to take care of her concerns (Smith and Rawling, 2008). Reference List Adams AP, Hewitt PB, Grande CM (editors) (1998): Emergency Anaesthesia, 2nd ed. Oxford University Press, 31-76 Caplan RA, Vistica MF, Posner KL, Cheney FW, (1997) Adverse anesthetic outcomes arising from gas delivery equipment: a closed claims analysis. Anesthesiology;87:741 Dorsh JA and Dorsh SE (1999) Understanding Anesthesia Equipment, 4th ed. Williams & Wilkins, 11-46. Ehrenwerth J and Eisenkraft JB (editors) (1993): Anesthesia Equipment—Principles and Applications. Mosby Year Book, 8-53. Jubran A, (1999). Advances in respiratory monitoring during mechanical ventilation. Chest; 116:1416. Kluger, MT., Bukofzer, M., and Bullock, M., (1999). Anaesthetic assistants: their role in the development and resolution of anaesthetic incidents. Anaesth Intensive Care; 27(3): 269-74. Lake CL, Hines RL, and Blitt CD (2001) Clinical Monitoring: Practical Applications for Anesthesia and Critical Care. WB Saunders, 36-144. Langeron O, Masso E, Huraux C, et al: (2002) Prediction of difficult mask ventilation. Anesthesiology;92:1217. May, A., Pettigrew, T., and Smith, R., (2007). Scotland vs. England: 'Anaesthetic Practitioner' or 'Physician Assistant-Anaesthesia. Anaesthesia; 62(5): 537-8. Meek, T., Gittins, N., and Duggan, JE., (1999). Cricoid pressure: knowledge and performance amongst anaesthetic assistants. Anaesthesia; 54(1): 59-62. Rosenblatt WH (2001) Airway management. In: Clinical Anesthesia, 4th ed. Barash PG, Cullen BF, Stoelting RK (editors). Lippincott, Williams & Wilkins, 133-176. Shelly MP and Nightingale P (1999). ABC of intensive care. Respiratory support. BMJ;318:1674. Smith, B and Rawling, P., (2008). Anaesthetic assistant competencies: our experience. J Perioper Pract; 18(5): 190-2. Read More