Case 4

Case 4

Please consider these five scenarios and associated questions below before reading the text of the tutorial.

Scenario A

You are called urgently to review an 8 year old child who, after a GA for manipulation of a forearm fracture, had returned to the ward 15 minutes before. You find him lying on his back with a nurse trying to ventilate him with a mask and bag. There is some respiratory effort but the airway is clearly obstructed. Suctioning the pharynx, putting the patient in the recovery position, insertion of an oral airway and application of jaw thrust corrects the problem, allowing spontaneous ventilation and return of good oxygenation. 30 minutes later the patient is easily roused and seems to be fine.

a) What may have contributed to this occurrence?

b) How would you avoid it happening again?

Scenario B

You have agreed to help a small district hospital in western Kenya develop a recovery area to support their twin operating rooms. There is a mains electricity supply to some parts of the hospital but currently no designated space or equipment for recovery. The nurse anaesthetist has sent you a list of 10 items that they want you to provide. Rank this list in order of importance; 1 for the most important 10 for the least important:

· Large tent (9 square metre base)

· Self inflating bag with facemasks and oral airways

· Elevating blocks for the foot of their non-tipping trolley

· DIY manual on electrical wiring

· An oxygen concentrator

· Pulse oximeter

· Sphygmomanometer

· Suction machine and catheters

· Battery operated lamp (torch)

· Hand bell

What are the reasons for your ranking?

Scenario C

The recovery nurse reports a BP of 100/40 mmHg and pulse rate of 90 following a spinal anaesthetic for open prostatectomy in a 70 year old man. She feels that he is a bit confused but appears well perfused. His preoperative BP was 150/90 and he was stable when you handed him over 15 minutes before. You can’t come out of the operating room immediately.

a) What are the possible causes?

b) What other information do you require immediately?

c) What advice will you give the nurse on further management?

Scenario D

You are a patient who is about to have lower abdominal surgery. Rank the following list of 10 possible immediate post-anaesthetic outcomes in the recovery period in order of desirability; 10 for most desirable and 1 for the least desirable

Nausea

Recall of surgery without pain

Gagging on an ET tube

Shivering

vomiting

residual weakness

somnolence

sore throat

normal (no problems)

pain

How might we prevent and immediately manage your three most undesirable outcomes?

a) What are the possible causes of this delayed waking?

b) How are you going to continue managing the case?

Additional points arising from the scenario questions

Scenario A

a) This case was discharged from the recovery area prematurely. Patients may appear to awake and reject a Guedel airway if vigorously stimulated, and will then later revert to the unconscious state with an obstructed airway. If a pre-operative or intra-operative opioid was given, this may be contributing. Once a fracture has been immobilised the patient has little need for continuing opioid analgesia and when left unstimulated will demonstrate the signs of relative overdose.

b) Good staff training and compliance with appropriate recovery area discharge criteria are required. Any nurse on a ward receiving patients from theatre should be familiar with managing an obstructed airway and a sedated patient. But they are unlikely to be as skilled as a trained and experienced recovery nurse in preventing and correcting anatomical airway obstruction.

Scenario B

There is no “right” ranking order but this is my personal ranking in order of importance to me:

1. Hand bell

Bells and whistles are excellent alarm systems as long as the recovery area is close enough to those who are expected to respond.

2. Sphygmomanometer

Essential monitor

3. Suction machine and catheters

Essential equipment

4. Self inflating bag with facemasks and oral airways

Important but requires training on effective use

5. Oxygen concentrator

A very useful investment if you have a reliable electricity supply.

6. Pulse oximeter

A review in 2004 concluded that available evidence “indicates that the value of peri-operative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency” (see further reading above).There are indeed acceptable clinical ways of detecting hypoxia but it is unlikely that many anaesthetists or recovery nurses would give up their pulse oximeters on the basis that others have to manage without!

7. Battery operated lamp

The head lamp variety in particular is very useful when there is a power cut; and this is much safer than a kerosene lamp in the presence of oxygen and/or ether! Battery replacement might be an issue. If you need one during the day near the equator, then you have the wrong location for the recovery area which should have good natural lighting; or you have forgotten to remove your sunglasses!

8. Large tent

If the criteria and standards for safe recovery are best provided in a tent, then so be it. But it might be more practical to obtain one there! 9 square metres is fine for one patient but if two bays are required then double the size.

9. Elevating blocks

This is one way of overcoming the lack of tilting trolleys and can be easily made. But there are other ways to achieve the objective of having the pharynx dependent e.g. a pillow can be placed under the dependent shoulder/thorax

10. DIY manual on electrical wiring

Never mess with somebody else’s electrical wiring however good you think you are at it! This is dangerous. It would be more appropriate to take a basic training manual for recovery nurses (see further reading above).

Scenario C

a) This man is hypotensive with the likely cause being one or both of the following:

Hypovolaemia due to continued bleeding.

· Vasodilatation due to continuing sympathetic blockade with reduced venous return that may have been masked earlier if his legs were in the lithotomy position for surgery.

b) You want to know his pulse rate, what is happening with bladder irrigation and wound drain. And if your recovery nurse is familiar with spinal anaesthesia, she should be able to report on the level of sensory blockade to cold and touch. If not, you will have to teach her later.

c) Immediate management is administration of oxygen, leg elevation and an IV fluid challenge with 500 mls saline/Ringers lactate. Ask her to report back within 15 minutes, but you must try to review the patient yourself before that time.

NB: patients who have had spinal anaesthesia have as many recovery needs as those who have had general anaesthesia.

Scenario D

Some occurrences after anaesthesia are more disturbing than others but most can be anticipated and prevented. A study in 1999 involved asking 101 patients to rank 10 possible immediate postoperative outcomes. Here is their combined response to that question with 1 for the least desirable and 10 for the most desirable:

1. Vomiting

2. Gagging on the ET tube

3. Pain

4. Nausea

5. Recall of surgery without pain

6. Residual weakness

7. Shivering

8. Sore throat

9. Somnolence

10. Normal (no problems)

I will not deal here with all these issues but it is important to think about how you could:

a) Prevent the most undesirable problems

b) Guide recovery staff in appropriate management when they do occur.

More information on this study can be found at:

www.jr2.ox.ac.uk/bandolier/booth/operations/anaespat.html

Scenario E

a) There are several causes of delayed wakening with apnoea after anaesthesia but the most likely possibilities here are:

A post-ictal state following an eclamptic seizure under anaesthesia; the lack of preoperative signs might put this low on your list. In addition one would expect to see good muscle tone.

Hypocapnoea following hyperventilation during surgery.

Overdose of opioids; this would be associated with other signs such as pinpoint pupils.

The patient may in fact be awake but paralysed with inadequate reversal of non-depolarising muscle relaxant or suxamethonium apnoea (unusual but likely in this case). Awareness would explain tachycardia and hypertension. A nerve stimulator will help here if you have one.

b) Ventilation may be required for some hours and you must ensure that sedation and analgesia are given on a continuous or regular and generous basis until spontaneous recovery from paralysis occurs. You clearly need to supervise this case personally in the recovery area, particularly if you do not have a critical care unit to which she can be transferred.

Reproduced with permission from

http://frca.co.uk/article.aspx?articleid=100744