Exploration of a Surgical Situation - Math Problem Example

Exploration of a surgical case study The patient (Mr Griffin) involved in the case study is 64 years old single Australian male, retired costume designer, of weight 70kg and height 5’8’’, admitted in the hospital for the repair of right inguinal hernia, with the length of stay of 0 to 7 days, requiring admission within 90 days under the Medicare scheme, requesting admission through rooms. In this essay we would discuss the anticipated questions from the patient on self-reading his report. The first question the patient may ask could be anaesthesia section, regarding the GA3 grade and airway management and why they are important? As known earlier, the inguinal hernia is a condition, where there is protrusion of the abdominal content through the inguinal canal, the most common day care surgery, and in the direct type, which occurs with increase in age, where there is weakness in abdominal fascia. (Lichtenstein & Shulman). The GA 3- means General anesthesia to be administered in the level as designated as 3 by American Society of Anaesthesiologist. General anesthesia is still the widely used and effective anesthesia advised for older adult, by many research studies. The General anaesthesia could be described as a state where the subject could feel absence of pain sensation- a state of unconsciousness with the absence of pain over the body. This is achieved either by administering the anaesthetic drugs through vein or breathed into lungs as gases that would be further carried to brain by blood. These stop the brain recognizing messages coming from the nerves in the body. Here the intravenous means, the drug given through the vein. The general anesthesia works by inhibiting the flow of a molecule called sodium in the brain, flow of which gives the feeling, memory and sensation to brain. The class three, means patient with definite functional limitation, (here a previous myositis, stroke, epilepsy, diabetic, hyper sensitive) etc as opposed to the also 1 healthy and 2 mild underlying disorders. The type and amount of anesthesia to be used varies with this classification. In the supine posture means the position of lying straight. In intravenous, the drug is given through a cannula injected into the vein. (Adachi etal.,2001). The airway management is important, as General anesthesia commonly interferes with the passage of gas (air) between the mouth and trachea, due mainly to the soft tissues of the oral-pharynx and relaxed tongue causing partial (or complete) obstruction. The skill of maintaining airway patency is fundamental to anesthetic practice. If an airway problem is not apparent until after anesthesia has commenced, a life-threatening situation can result. Assessment of the airway preoperatively is clearly one of the anesthetist’s prime goals. (http://en.wikipedia.org/wiki/Herniorrhaphy, viewed, 2007). The Preoperative airway assessment attempts to identify two potential hazards: The patient in whom the airway is difficult to maintain manually The patient in whom it is difficult or impossible to successfully visualise the larynx with a laryngoscope. The features (Appendix 1) are usually observed and caution is taken care of in pre anaesthesia check up. Another important point of concern when administering the general anaesthesia would be the loss of protective airway reflexes and patency as coughing, as there is a loss of consciousness among the subject. At times a loss of regular breathing pattern as the residual effect of anesthetics, opiods and relaxants could also be observed. In this condition a breathing tube is inserted after the patient becomes unconscious. This helps the anaesthetist to maintain an open airway, rendering him control over breathing regulation. Thus a device that helps in mechanical ventilation includes an endotracheal tube – intubations, and other alternative devices such as facemasks or laryngeal mask airways. Thus it could be understood that airway management is a main issue in general anaesthetics and it involves both instrumentation and mechanics , though mechanics that is too technical not discussed here. It could also be understood that anesthesist employs drugs to facilitate the manipulation and instrumentation of the airway and also to overcome the path physiologic problems that may further cause airway obstruction. (Wenker, 1999). On an average basis, five major challenges can be expected in airway management. The five challenges that anaesthetist could face includes, (1) overcoming the airway obstruction; (2) taking care to prevent pulmonary aspiration; (3) performing a effective endotracheal intubations (4) normalizing the pulmonary function during intermittent positive pressure ventilation (IPPV); and (5) restoring spontaneous ventilation and airway protective reflexes. Another concept that is of importance is a case where an Obstruction to gas flows might arise from an obstruction through foreign object, including food or from path physiologic processes as trauma, edema that could cause airway structures. In the anesthetized or comatose patient, loss of muscle tone can allow the tongue or epiglottis to collapse and cause obstruction. That is why fasting the night before the surgery is advised. This is done to avoid the respiratory distress syndrome. On explaining physiologically, the upper airway (above the larynx/epiglottis) has a shared atrium – a valve that leads to the lungs, where the gas exchange occurs and gastrointestinal tract that contains fluids and nutrition. At situations, if overnight fasting is not observed, a passive regurgitation or active vomiting may occur that would in turn accumulate gastric contents in the pharynx places the patient at risk of pulmonary aspiration. This risk of regurgitation is high when the airway reflexes (as glottic closure, coughing) and voluntary avoidance manoeuvres are suppressed (e.g., anesthesia, coma). These particulate matter can affect in two ways, by obstructing the tracheal bronchial tree and by injuring the lung parenchyma due to high acidity (pH < 2.5). This in turn brings around the pneumonitis that causes significant morbidity (e.g., ARDS [acute respiratory distress syndrome]) and mortality. It could be now understood that Intravenous systemic drugs are administered to obtund the cough reflex. The drug, intravenous lidocaine (1–2 mg/kg) when injected, transiently obtunds the cough reflex without significantly affecting spontaneous ventilation. Another risk of stimulating the central nervous system and seizure-like activity is prior reduced by administering, small doses of an intravenous barbiturate or benzodiazepine. The Intravenous opioids drugs prescribed, suppress cough reflex. But routinely, a combination of an intravenous opioid with a major tranquilizer is used that allows tolerance of an endotracheal tube without affecting the spontaneous ventilation. The opioids thus not only obtund the cough reflex that closes the larynx, but also limis the autonomic sympathetic responses as hypertension and tachycardia to endotracheal intubations (Henry Rosenberg, 2006). Another group of drugs used are skeletal muscle relaxants that are commonly used with a general anesthetic to facilitate the manipulation of the head and jaw to prevent reflex closure of the larynx. During anaesthesing, two procedures are commonly used to ensure smooth surgery. First is the maintenance of oxygenation by the supply of Pure oxygen by mask when the patient is still awake that eliminates nitrogen from the lung. This is followed by administratiom of an intravenous anesthetic (e.g., thiopental) rapid-acting neuromuscular blocker (e.g., succinylcholine). As the maximum effect of the muscle relaxant is vivid (30–90 s), laryngoscopy is performed where a endotracheal tube is inserted, the tracheal tube cuff is inflated, and the position of the tube in the trachea is verified. Alternatively, in conditions where the risk of pulmonary aspiration is minimal, presumably empty stomach, the patient is anesthetized and paralyzed while ventilation is supported by intermittent positive pressure delivered by face mask. Then at the appropriate time, laryngoscopy is performed and the endotracheal tube is inserted. Thus generally the anaesthesiologist tailors the anaesthetics plan according to postoperative expectations. For example in the case of a relatively healthy patient , extubated in the operating room, the goal of the anaesthetist would be to have the patient breathing spontaneously with intact airway reflexes and at a arousal state to command immediately after operation. Thus here challenge is to satisfactorily maintain a general anesthetic state during the surgery but to have the patient recover from anesthetic drugs, including hypnotics and opioids, immediately afterwards. When this is not feasible, the patient is transferred to the PACU (post-anesthesia care unit) that gives additional time for eliminating the drugs that depress spontaneous ventilation and cough reflexes from the body. As an another way, anaesthetist also administer an opioid antagonist (e.g., naloxone) and/or benzodiazepine antagonist (e.g., flumazenil) etc. But there is always a risk of occurring sudden awakening, anxiety, pain, uncontrolled autonomic sympathetic activity, and recurrent ventilatory depression because of mismatching antagonists and residual anesthetic drugs. The second question may be regarding the mesh used. The surgical procedure requires fasting as any material present in the stomach might on anesthesia regurgitate and enter the lungs, which is fatal. The surgery is tension free, open mesh type done under general anesthesia. The "tension-free" repairs is a process of placing a synthetic mesh in the inguinal region to strengthen it . At times , 2-layered mesh device is placed over and behind the defect as in the Prolene Hernia System. The meshes that used are of materials as polypropylene or polyester, although now a days materials as Teflon meshes and partially absorbable meshes are also available. Once the anesthetic has taken effect, a single cut (about five to 10cm long) is made in your groin, and the bulge is pushed back into place. Then a synthetic mesh is stitched over the weak spot to strengthen the wall of the abdomen. The skin cut is then closed with dissolvable stitches. Thus in the open mesh repair, of the Lichtenstein type, a ‘tension-free’ repair, synthetic mesh, commonly polypropylene, measuring 15 x 10cm is sutured to the inguinal ligament below and the conjoint tendon above. In this way the entire myopectineal orifice is covered. As there is no suture line under tension, so there is less postoperative pain and more rapid return to normal activities. Thus the mesh a surgically designed, sterile woven material, made from a synthetic plastic (i.e.: Polypropylene), specifically used to repair hernias at the. These sterile mesh "patches" or "screens" are wafer thin, soft and pliable or flexible to easily conform to body's movement, position and size. They are also quite strong and effective in repairing hernia completely and immediately. They are available in several varieties, shapes and sizes and are usually tailor made for individuals.(Crespi etal.,2004) As it is known that any foreign material placed in the body is a potential source for infection, however years of experience using mesh in inguinal hernia repairs have not shown this to happen often. Hundreds of thousands of cases are performed each year without problem. Unlike silicon breast implants, there are no known effects on the body of having mesh placed in it. The desirable or ideal mesh properties include the inertness, resistance to infection, molecular permeability, pliability, transparency, mechanical integrity, and biocompatibility. There are certain drawbacks as the absorbable mesh that is widely used now a day doesn’t remain for longer time in the wound till adequate collagen is deposited, and the multi-filament mesh used harbours bacteria. Thus the monofilament mesh is the most popularly used are made of polypropylene that has characteristic advantages. The use of porous mesh – the polypropylene, allows a large surface area for in-growth of connective tissue leading to permanent fixation of the prosthesis within the abdominal wall. When the mesh is placed Intraparietally, the prosthesis allows well vascularized, tissue coverage. Latest research reports have proved that fears of complications related to mesh implantation are baseless.( Mokete,& Earnshaw ,2001) From this it could be understood that the mesh not merely covers the hernia defect alone f, but most importantly reinforces an area of ever-present thinned and weaken tissue that surrounds all hernia defects. Unlike as is the case in many other hernia repair techniques, this technique surrounds the weakened vulnerable are the Myopectineal Orifice, thus reducing the risk of a recurrent hernia . Above all , the sterile mesh acts as a "lattice", "growth bed" or "scaffolding" for new tissue ingrowths, Which further 'heals the defect with time,. This surgery thus allows the full incorporation of the mesh, safely and comfortably, into the muscle wall itself. (Leigh Neumayer etal.,2004) As the mesh is thin, pliable and flexible, the patient is totally unaware of its presence and any of his activity is not limited after hernia surgery. The hernia repair here can be said as immediately being, strongly, effectively and completely repaired by the mesh leading to less post-operatively restrictions. Thus in this procedure the mesh is safely placed under the muscle defect where it is very effective and could not be later lifted off or separated by abdominal pressure or strenuous physical activity (Parra etal.,2004) appropriate sources , for each question that would help patient to obtain further information ? For the anesthetic record understanding, 1. MA Thaha, P Sanjay, A Woodward, RJC Steele,2007 , Anaesthetic techniques for open inguinal hernia repair in adults ,Cochrane Database of Systematic Reviews 2007 Issue 3 (Status: New) http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006684/frame.htm 2. Jennifer Sisk, Encyclopedia of Medicine, Published December, 2002 by the Gale Group, article was updated on 08-14-2006 http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/anesthesia_general.jsp General anesthesia. These two websites gives a concise fact about general anesthesia, the pre anesthetic parameters, and the anesthetic monitors etc in a simple terminology. Alternatively if website assess is felt to be cumbersome, any information about anesthesia could be obtained from the American Society of Anestheologist . Since its founding in 1905, the Society's achievements have made it an important voice in American Medicine and the foremost advocate for all patients who require anesthesia or relief from pain. ASA is the largest anesthesiology organization in the world with more than 41,000 members. Or two books that gives lucid, simple and understandable information about the air way management and general anesthesia would be , Clinical Anesthesia Procedures of the Massachusetts General Hospital, By William E Hurford, Michael T Bailin, J. Kenneth Davison, Kenneth L Haspel, Carl E Rosow, William E. Hurford Anesthesia Secrets: with STUDENT CONSULT Access (Secrets) by James Duke For the surgical method and mesh procedure: 1. he hyperlink, http://hernia.tripod.com/inguinal.html 2. The BUPA fact sheet , http://hcd2.bupa.co.uk/fact_sheets/html/inguinal_hernia.html These two web sites in a understandable language explain the surgical procedure, why is it advantageous and explicitly about the mesh. Alternatively journal references that gives a wide concise, effective knowledge about the mesh procedure, Current approaches to inguinal hernia repair.  The American Journal of Surgery, Volume 188, Pages 9-16 S. Awad, S. Fagan Prospective randomized trial of polypropylene mesh compared with nylon darn in inguinal hernia repair,A. Koukourou, ,W. Lyon, J. Rice and D. A. Wattchow British Journal of Surgery 88 (7), 931–934. doi:10.1046/j.0007-1323.2001.01818.x The entire four web sited could be accessed through the Google search, the powerful search engine in the internet explorer. Two aspects in the chart that was very helpful: Progress notes The progress report is beautifully listed and documented, that gives out complete case history of the patient, so it becomes easy for any future validation of the procedure. Even for any other future medical surgery, this report could be very good base. Above all this is easily understandable for patient except for few medical terminologies. It includes the physical parameter, social conditions, medication undertaken all under one roof. The writing in this section was understandable with terms that the patient would have known already. Anesthetic record The pre anesthetic health questionnaire is complete in itself, without leaving any details or ambiguity prior to the aesthesia procedure. it is again very lucid and is in a easy language without much medical jargon. The anesthetic record contains all relevant medical history, medication, drug allergy report and anesthetic report. Two aspects in the chart that was difficult to explain: Operative report Recovery report Both the reports were difficult to explain as they were full of medical terms short forms, values and graphs, without any note of whether it is normal, without any parameters being mentioned. In this section as patient’s notes, though time consuming, the full forms and whether the condition is normal could be mentioned. The hand writing could be more legible or alternatively could be typed or taken as print outs. As an added remark, the operation report could have included the post operative medication and the care should have been taken. The progress notes has many short forms using which the patient cannot find meaning even in medical dictionary. The handwriting was in legible in progress notes and anaesthetic record with over writing, writing not in the appropriate place etc. doctors can write little more legibly or involve a nurse practitioner to write and then supervise it, or alternatively can type it clearly without abbreviations. In all the four points, the anticipated patient’s reaction would be their quest to understand the medical terminologies, used to describe their position which has to be patiently explained. The doubts whether the values entered in the records would be normal or some thing to worry, and the past medical histories impact on the recovery from the surgery. APPENDIX 1. Factors considered during airway assessment Anatomical features which may warn of a difficult laryngoscopy Appearance of the face, maxilla, mandible and neck Short, muscular neck Jaw movement Protruding incisors Head extension and neck movement High and long arched palate Dental condition Receding lower jaw (micrognathia) View of the oro-pharynx Poor mouth opening Chest and cervical spine X-rays Previous anesthetic records Read More