Reflection on Failed Spinal Anaesthesia: Clinical - Essay Example

REFLECTION ON FAILED ANAESTHESIA: CLINICAL This reflection presents the complete care which the patient was able to experience as far as the anaesthetic process is concerned while undergoing right knee replacement. During the process, a critical incident involving failed spinal anaesthesia will be discussed including the plan to shift to general anaesthesia. The overall care of the patient, from his physical, psychological, to his pharmacological care, including the functions carried out by the anaesthetic assistant would also be considered. The Royal College of Anaesthetics have pointed out the critical incidents are those which can cause harm and could have been anticipated with the use of changes in the process (Cassidy, et.al., 2011). Spinal anaesthesia is a very reliable surgical method because it is a very uncomplicated and straight forward technique (Wenk, et.al., 2012). The target area to be covered anatomically can easily be predicted, especially if the anaesthesia is appropriately introduced. However, failure may still be possible. An effective block would be sufficient in cases where the quality is up to standard, or when the duration is sufficient or when it is adequately intense (Abdallah, et.al., 2013). The patient in this reflective essay shall be referred to as Robert to protect his identity in compliance with the provisions of the 2015 Nursing and Midwifery Council (NMC). He is 48 years old, generally healthy and has had no adverse medical incidents in the past. He was admitted however for revision of left knee replacement. Overall, he is healthy and had previous experiences with local and general anaesthetics. His BMI is in the normal range (28) and weighs 180 lbs. and height of 5’9”. According to the grading provided by the standards of the American Society of Anesthesiologists, he is of grade 1 status which basically translates to a rating of a normal and healthy patient (Daabiss, 2011). An anaesthetist examined him and he was later admitted into the elective unit. For his surgery, an operating room/theatre was prepared and prior to his entry into the room/theatre, the usual pre-operative checks were conducted. I checked the anaesthetic machine for possible defects of leaks, based on the 2004 standards indicated by the Association of Anaesthetists of Great Britain and Ireland (AAGBI), including the local trust guidelines and standards. Equipment for monitoring was also assessed based on the 2007 standards indicated by the AAGBI. The ABCD guidelines were also evaluated (Davies and Yesudian, 2013). This refers to airway, breathing, circulation, and drugs. I turned on the ventilator and checked it also for possible equipment defects. The ventilator is important as the anaesthetist uses it to undertake other tasks and can be hands free for such tasks. IV fluids and drugs for induction were all prepared. There were also various sizes for the ET tubes made ready. More often than not, the sizes for ET tubes are based on gender, the patient’s weight, and the size of the patient. For adults, the cuffed tubes are often recommended, especially with the risk of aspiration ever present for these patients. For males, size 8 is usually prepared and for females, a smaller size 7 is usually prepared. Physiologically speaking, the size of the trachea is larger in males than in females, hence the difference in ET tube sizes (Karmaker, et.al., 2014). Choosing the correct tube size is important because proper seal and possible aspiration risk may be an issue where there is inadequate cuff seal around the trachea (Orsborn, et.al., 2015). Moreover, where the cuff is high-pressured, the laryngeal cord may suffer ischemia of the local area, and this can severely injure the walls of the trachea (Orsborn, et.al., 2015). I also proceeded to check the apparatus, including the anaesthetic machines, ensuring that they were properly disinfected based on the infection control standards (Infection Control Policy, 2010). From the Elective Admission Unit, Robert was wheeled into the pre-operative room. I introduced myself to him and then along with the on duty pre-operative staff, I proceeded to carry out the necessary checks for him. The checks covered various pre-operative details essential for the surgery. This is one of the checks to ensure that we have the right patient for the right procedure (Dower and Manninen, 2012). I also checked the consent form was signed and confirmed the same with him as consent is a legal requirement for any medical procedure (Dower and Manninen, 2012). In the consent process, the patient would be informed about his condition, the surgery or procedure to be undertaken, its risks, possible complications, and the impact of the intervention (Ismael and Gibson, 2015). In doing this the patients decision-making is based on balance of probability between risk and benefit of the procedure, he is also given the opportunity to ask questions about the procedure to allay his anxiety (Ismael and Gibson, 2014). In gaining informed consent, the medical personnel is upholding the ethical principles of the practice, specifically that of ensuring patient autonomy (Shukla, et.al., 2012). It can also prevent any possible legal charges of negligence against the medical personnel, especially where the patient would claim lack of information (Shukla, et.al., 2012). As part of the pre operative preparation, the anaesthetist is tasked with reviewing the patient, including his blood group. Where haemorrhage or hypovolemic shock is a possible complication during the surgery, the patient’s balance of fluids has to be evaluated with related electrolyte assessment to support and ensure homeostasis (Scozzafava, et.al., 2012). It is vital to maintain adequate blood pressure during procedure to ensure that tissues are adequately perfused (Scozzafava, et.al., 2012). There are different blood antigens and some can lead to reactions during blood transfusion. Where the patient’s life is at risk, an O-negative blood stored in the pathology unit may be administered (Crocker and Norris, 2012). It is important for anaesthetic assistants to know how to secure assistance during possible incidents of major patient bleed. To ensure preparedness, the switchboard has to be informed that a Porter is required and another call has to be made to the pathology unit during major haemorrhage (Oaks, et.al., 2012). It is also important to ensure that the patient’s haemodynamics are within acceptable levels during surgery (Raboel, et.al., 2012). In instances where major haemorrhage occurs, invasive monitoring has to be carried out where an arterial line can be inserted to acquire accurate blood pressure readings and to make accessible arterial blood gas samples (Raboel, et.al., 2012). Equipment needed include: arterial pack, abbocath, skin antiseptic, and arterial cannulas. In these instances, I will also need to prime with normal saline a transducer giving set in order to guarantee that air is not present. With the transducer, the resistance of current measures can be converted into electrical digits (Yarham, et.al., 2012). this is in anticipation of probable haemorrhagic emergencies (Yarham, et.al., 2012). Still, in instances where a central venous line would be needed to ensure sufficient haemodynamic measures, there may be a need to carry out the rapid infusion of fluids as well as the delivery of inotropes such as epinephrine (Yarham, et.al., 2012). A CVP or a central venous pressure line would have to also be inserted. The administration of inotropes such as epinephrine will increase the heart contractility also cardiac output and vasopressors will also lead to constriction of the blood vessels which can then lead to higher blood pressure (Gaies, et.al., 2013). It is important for anaesthetic assistants such as myself to prepare a CVP pack, skin antiseptics, ultrasound machine, multi-lumen CVP catheters, and a transducer set (with normal saline). The patient is positioned with his head lower than his legs and his head shifted to the left to provide access to the right jugular vein (Crosby, 2012). In having a good perspective and understanding of the human body, including why interventions are carried out in a certain way has improved my skills and vigilance in these invasive procedures. As I have familiarized myself with the equipment and procedures, I have gained more confidence as I am able to formulate contingency plans in my head and I have improved my skills by applying my anticipation into my readiness and competence to carry out my functions effectively as an anaesthetic assistant. The preoperative checklist is used to carry out final confirmation of the patient’s identity, verbally and personally asking him what his name is, checking that his armband matches his name. This procedure is carried out in order to prevent any medical and surgical errors (Garrouste-Orgeas, et.al., 2012). I would also check that the consent form is signed and I would again confirm that he has understood what he signed in the consent form. His date of birth, as well as his National Health Services number would also be confirmed. In the case of Robert, his name was properly confirmed, including his consent form, and the site of the surgery on his body was also marked. The patient’s allergies to food, drugs, including latex was also determined. As already mentioned, the anaesthesia safety check was carried out with the procedure to be carried out during the anaesthesia induction also discussed with the patient. The pre-operative care plan was discussed with the patient, and I verified that Robert has not eaten anything for six hours and has not drunk water for the past two hours. I asked him if he was wearing dentures, or if he had loose or false teeth. He said he was not wearing any dentures, nor did he have any loose of false teeth. I also asked if he has had any metal work done on his body including piercings, or whether he was wearing any jewellery. He said he did not have any piercings nor was he wearing any jewellery. He was also not wearing any hearing aids. It is important to undertake this process because these are standard pre-operative checks prescribed by the WHO in order to ensure successful and safe surgeries (Pickering, et.al., 2013). He also mentions that he was not wearing nor did he ever wear anti-embolitic stockings to prevent the occurrence of Deep Vein Thrombosis (DVT) (Pop, et.al., 2013). The general patient plan was to carry out the spinal anaesthesia with the anaesthetist telling Robert about the spinal anaesthesia which would be used on him and the possible dangers in such procedure. It is important for the patient to know after the discussion with the anaesthetist, that with the type of anaesthesia to be used on him that he may actually remember some stages of the operation, and sometimes feel something during the surgery. He would however be assured that he would not feel pain during the surgery. The patient therefore has to be able to express possible feelings of electric shock during the surgery and for him not to mistake this for a ‘burning’ feeling (Suppa, et.al., 2012). Positioning follows as an important stage in the preparation. This can be a complex and tedious process especially where the staff does not known why the positioning of the patient is important (Hermanides, et.al., 2012). However, it is important to understand that a wrong position for the patient may lead to the failure of the spinal anaesthesia (Hermanides, et.al., 2012). Overall practice indicates how various assistants are sometimes not aware about the different positions available, when they would be used, and why such positions are chosen. Different procedures required different approaches. I have to make sure that the airway is secure, properly taped and free from any pressure contact with the skin. The anaesthetic machine may sometimes be positioned differently to ease access to the airway. In some obstetric cases, positioning the patient lithotomy may be essential. The legs may have to be shifted together in order to ensure that no nerve damage is caused. Medical practitioners have to know about this position especially where the surgery would be a protracted one (Neumann, et.al., 2013). In Robert’s case, he is best seated during the anaesthesia induction (Neumann, et.al., 2013). I helped him sit at the edge of the trolley with pillows under his arms and then I asked him to position his back out, moving his chin down to his chest in order for the anaesthetist to feel his vertebrae. I continuously reassure Robert to ease his anxiety and letting him know what is happening. This procedure would allow for the 3rd and 4th lumbar vertebrae to make space and for the anaesthetist to be able to locally secure the Tuffier line and ensure a successful puncture (Lyons, 2013). I was very conscious in helping Robert get into the right position. I supported positioning while maintaining dignity and respect for the patient. I explained that I had to anchor his shoulders in order to secure him in a position, especially as he needed to be immobile while the needle was being inserted into his spine (Neumann, et.al., 2013). In the projection as well as the puncture stage, the anaesthetist would have a midline approach. In this procedure, I had to secure a sterile tray and the patient’s back swabbed with a sterile wipe. The needle has to be held very much like a pencil and it is therefore important for me to prevent the patient from making any sudden movements. I helped ease Robert’s nerves and anxiety, talking with him now and then and even letting him know what was happening. He felt better about knowing what was actually being done on him. Nurses have a major task in easing patient anxiety, talking with them and giving them the necessary information they would need to ease their worry (Ting, et.al., 2013). Where the cerebrospinal fluid or CSF would not be seen in 30 seconds, bone would likely have been encountered. The needle has to be retracted. In case the patient reports sharp pain in his legs, the needle should also be removed. Another attempt at needle insertion should be tried especially as the midline principle is already violated. Where the successive attempts are still not successful, general anaesthesia has to be used instead. More traumas can be caused with repeated unsuccessful attempts at spinal anaesthesia (Kumar, et.al., 2014). Experts claim than two to three attempts are the threshold (Kumar, et.al., 2014; Ting, et.al., 2013) for spinal anaesthesia attempts, especially with many spinal punctures possibly leading to injuries in the nerves and causing hematoma in the area. In using the paramedian technique, anatomic thresholds may not be as limited (Baumann, et.al., 2011). Nevertheless, a possible mistake in this technique is of the insertion being too far away from the midline. Palpation is applied in order to secure the caudal tip. The needle applied in this technique is much longer (Baumann, et.al., 2011). The next crucial stage following anaesthesia induction is the placement of the monitoring block. It is important to have a sensory block test with cold spray in order to determine the readiness for the operation (Justiz, et.al., 2012). This is in order to ensure that sensation on the surgical area has been numbed. It is also important to monitor the blood pressure every three minutes with the patient’s level of consciousness continually monitored (Hasegawa, et.al., 2015). This is to ensure patient is in stable condition during the procedure and any changes therefore may indicate activation of contingency plans. The spinal anaesthesia block for Robert was sufficiently supported by the different guidelines in surgical and anaesthetic practice, however, it was still not successful. The anaesthetist then shifted to general anaesthesia. I told Robert that there was no cause for alarm and I helped ease him on to the bed, still monitoring his physiological and psychological well-being. Previously, I was already able to check and prepare all the necessary equipment for general anaesthesia. After verifying what airway adjunct the anaesthetist would use, I proceeded to prepare the adjunct and also prepared the necessary anaesthetic agents (specifically Fentanyl 100mcg in 2ml). Propofol was also prepared and the different syringes were properly and accurately labelled. Propofol is an oil-in-water emulsion administered as a single dose of 1.5 to 2.5 mg/kg. It is often used in general anaesthesia mostly as it helps speed up recovery and to also decrease residual side effects. Pharmacological options are based on the time required for the surgery. Some local anaesthetics are often applied in spinal anaesthesia like procaine, lidocaine, teracaine, and bupivacaine. There are short acting anaesthetics which are used for surgeries which may only last for 90 minutes or less. These include procaine and lidocaine. Tetracaine and bupivacaine on the other hand are used for surgeries which may take more than 90 minutes. It is important to know the correct dosage, the correct mode of administration, and more importantly, to check that the right medication is administered to the patient in order to prevent any medical errors (Cleary, et.al., 2010). The National Health Services, specify the importance of vigilance in order to ensure that appropriate drugs are provided for patients (Cleary, et.al., 2010). All the medications administered by medical personnel has to be double-checked and managed based on the standards set for Medicinal Products and National Policy of Misuse of Drugs Regulations and Safe Custody (2001). Under these conditions, the ampoule’s expiry date was checked with the anaesthetist, including the name of the medication (NMC, 2008). The laryngeal mask airway cuff was reduced with its posterior area also lubricated. Robert was then placed in a position very much like he would be sniffing the air. This is for pre-oxygenation in order to prevent transient hypoxaemia (Sreejit and Ramkumar, 2015). Preoxygenation helps ensure that sufficient oxygen is available in the lungs to support a long period of apnoea (Stolady, 2015). The anaesthetist then proceeded to insert the cuff into the pharynx and the ventilation device was then secured. General anaesthesia can also be managed using an ET tube. The ET tube position would be determined based on capnography with the anaesthetist auscultating for air entry. Bilateral chest movement is verified further through the misting of the tube, and also noting air movement at the ends of the tube (Scott, 2012). I also assisted with the medical staff in order to ensure a patent airway for the adult patient while using an ET tube, a laryngeal mask, as well as an oropharyngeal and naso-pharyngeal airway. The Guedel or the oropharyngeal airway and the nasopharyngeal airway are simple adjuncts which help ensure a patent airway (McPherson, 2012). I prepared the Guedel for use by the anaesthesiologist. It was used to prevent backward tongue displacement as well as soft palate obstruction. I determined the size of the oropharyngeal airway by establishing the distance between the incisors and the jaw angle (McPherson, 2012). During the insertion of the airway, I made sure suction was ready and available to clear the airway of any possible secretions or foreign bodies (McPherson, 2012). This model helped develop my skills and knowledge as an anaesthetic nurse/assistant. In reflecting on the above case applying the Gibbs reflective process, I was able to understand how important preparation is. This reflective process covers a full-structured debriefing which covers the initial experience with a description of what happened in the critical incident. The next stage of the reflective cycle would present the reactions and feelings of the reflecting individual. Evaluation would follow, where the good and the bad of the experience is evaluated. Analysis is next where the reflecting individual would try to understand the situation, considering ideas from different parties, and their experiences. Following the conclusions are action plans for possible future actions in order to improve practice. This reflection was chosen because it is detailed enough to cover all the essential elements of the critical incident. Preparation in this case helped ease the transition from the failed spinal anaesthesia to the general anaesthesia. There was less stress for the staff and for the patient and no time was lost as well as harm was minimized. If I was not prepared with the alternative anaesthetic option, the other staff members would have been stressed and anxious during the transition and during the surgery itself. By being prepared, I was able to ease the patient and the medical staff’s worry and anxiety. References Abdallah, F. W., Halpern, S. H., & Margarido, C. B. (2013). Transversus Abdominis Plane Block for Postoperative Analgesia After Caesarean Delivery Performed Under Spinal Anaesthesia? A Systematic Review and Meta-Analysis. Survey of Anesthesiology, 57(3), 154-155. Bauman, J. A., Hardesty, D. A., Heuer, G. G., & Storm, P. B. (2011). 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