Case Study Majri

April 10, 2023April 10, 2023 GA+EPIDURAL - TAHBSOGA+EPIDURAL - TAHBSO 11

CASE STUDY ON THE USE OF CASE STUDY ON THE USE OF COMBINED GENERAL ANAESTHESIA COMBINED GENERAL ANAESTHESIA

WITH EPIDURAL FOR PATIENT UNDER WITH EPIDURAL FOR PATIENT UNDER GONE TOTAL ABDOMINAL GONE TOTAL ABDOMINAL

HYSTERECTOMY BILATERAL HYSTERECTOMY BILATERAL SALPIGO-OOPHORECTOMYSALPIGO-OOPHORECTOMY

PPP MAJRI BIN ABASPPP MAJRI BIN ABAS

PAC 2/2008PAC 2/2008

April 10, 2023April 10, 2023 GA+EPIDURAL - TAHBSOGA+EPIDURAL - TAHBSO 22April 10, 2023April 10, 2023 GA+EPIDURAL - TAHBSOGA+EPIDURAL - TAHBSO 22

IntroductionsIntroductions

Anaesthesia involves the administration of Anaesthesia involves the administration of potentially lethal drugs and gases. Care of potentially lethal drugs and gases. Care of patient for pre, intra and post operatively patient for pre, intra and post operatively play important role, also to provide a play important role, also to provide a maximum safety and comfort for the maximum safety and comfort for the patient.patient.


General objectiveGeneral objective

By doing this case study on the use of By doing this case study on the use of combined general combined general anaesthesiaanaesthesia with with epidural for patient under gone total epidural for patient under gone total abdominal hysterectomy bilateral Salpigo-abdominal hysterectomy bilateral Salpigo-oophorectomy is to ensure that all oophorectomy is to ensure that all preparations for patient undergone surgery preparations for patient undergone surgery will be successful and reduce pre, intra will be successful and reduce pre, intra and postoperative complicationsand postoperative complications


Specific ObjectiveSpecific Objective

To participate in technique using in To participate in technique using in giving anaesthesia, rapid giving anaesthesia, rapid sequence sequence induction. induction.

To improved skilled when performing To improved skilled when performing cricoids pressure and the important of cricoids pressure and the important of cricoids pressure.cricoids pressure.

To provide care of patient for pre, intra To provide care of patient for pre, intra and post using nursing process.and post using nursing process.


Anatomy and physiology of the Anatomy and physiology of the system involved.system involved.

Respiratory System


Anatomy Epidural SpaceAnatomy Epidural Space



Anatomy of female Anatomy of female reproductive systemreproductive system



Patient ParticularPatient Particular

Name : Mrs S: Mrs S

IC NO.IC NO. : 590218105044: 590218105044

RN.RN. : 1171118: 1171118

AgeAge : 49 years old: 49 years old

SexSex : Female: Female

Race Race : Malay: Malay



Present HistoryPresent History

Had abdominal swelling since Had abdominal swelling since

June 2007June 2007

Only sought 7 timesOnly sought 7 times

On April 2008 diagnosed as On April 2008 diagnosed as

ovarian carcinomaovarian carcinoma



Past Medical And Past Medical And Surgical HistorySurgical History

No known medical illnessNo known medical illness

No history of chest pain/orthopneaNo history of chest pain/orthopnea

No known allergy of drug and foodNo known allergy of drug and food

Known case of migraine especially Known case of migraine especially

pre menstrual last attack 2003, pre menstrual last attack 2003,

now much betternow much better



No surgical historyNo surgical history

Obstetric history – Para 3, full Obstetric history – Para 3, full

term spontaneous virginal term spontaneous virginal

deliverydelivery



Treatments Treatments

Tablet Propanolol 40 mg. BD for Tablet Propanolol 40 mg. BD for migraine prophylaxismigraine prophylaxis



InvestigationsInvestigations

Full Blood Count Full Blood Count

BUSEBUSE

RBSRBS

ECGECG

Chest X-Ray Chest X-Ray



Type Of Operation Type Of Operation PlannedPlanned

Combined general anaesthesia with Combined general anaesthesia with epiduralepidural

April 10, 2023April 10, 2023 GA+EPIDURAL - TAHBSOGA+EPIDURAL - TAHBSO


Definition of General Definition of General anaesthesiaanaesthesia

General anaesthesia is a treatment that puts General anaesthesia is a treatment that puts you to sleep during medical procedures, so you to sleep during medical procedures, so you do not feel or remember anything that you do not feel or remember anything that happens. General anaesthesia is commonly happens. General anaesthesia is commonly produced by intravenous drugs or inhaled produced by intravenous drugs or inhaled gasses.gasses.

The "sleep" you experience under general The "sleep" you experience under general anaesthesia is different from regular sleep. anaesthesia is different from regular sleep. The anesthetized brain does not form The anesthetized brain does not form memories or respond to pain signals.memories or respond to pain signals.



General Anaesthesia is the most common type of General Anaesthesia is the most common type of anaesthesia for surgery. You will be in a sleep state anaesthesia for surgery. You will be in a sleep state during the surgery. You will have no pain. You will during the surgery. You will have no pain. You will remember little about the surgery or recovery period. remember little about the surgery or recovery period. There are several methods of giving general There are several methods of giving general anaesthesia. Many aesthetic drugs are now available, anaesthesia. Many aesthetic drugs are now available, and they help make your anaesthesia safer than ever and they help make your anaesthesia safer than ever before. The selection of which drugs are used depends before. The selection of which drugs are used depends on your physical condition and the type of surgery you on your physical condition and the type of surgery you are having. Injecting medicines into a vein, or having you are having. Injecting medicines into a vein, or having you breathe a gas from the anaesthesia machine administers breathe a gas from the anaesthesia machine administers usually general anaesthesia.usually general anaesthesia.



Definition of Regional Definition of Regional Anaesthesia Anaesthesia

Regional Anaesthesia is used to Regional Anaesthesia is used to numb only a specific part of the numb only a specific part of the body. A local aesthetic (numbing body. A local aesthetic (numbing medicine) is injected into the area, medicine) is injected into the area, where it blocks pain sensations. where it blocks pain sensations. There are many types of regional There are many types of regional anaesthesia. The most common are: anaesthesia. The most common are: spinal, epidural, and Bier blocks. spinal, epidural, and Bier blocks.



Epidural anaesthesia is a neuraxial Epidural anaesthesia is a neuraxial technique offering wide range of technique offering wide range of applications for procedures below the applications for procedures below the neck level. An epidural block can be neck level. An epidural block can be performed at cervical, thoracic, or performed at cervical, thoracic, or lumbar levels. Since autonomic, lumbar levels. Since autonomic, sensory and motor block occur with an sensory and motor block occur with an epidural, it can be used for surgical epidural, it can be used for surgical anaesthesia where relaxation is anaesthesia where relaxation is required.required.



Indication of General Indication of General anaesthesiaanaesthesia

For airway protection since case For airway protection since case need to be done under general need to be done under general anaesthesia anaesthesia

Case cannot be done spinal Case cannot be done spinal because this is a major because this is a major operation.operation.

Patient treats as full stomach Patient treats as full stomach condition because she had mass condition because she had mass in abdomen cavity.in abdomen cavity.

Long time operation 4 hours.Long time operation 4 hours.



Indication of Epidural

postoperative pain control


Preparations

Preparation of equipment (MALES)GA machine - checked for leaking Airway – oropharyngeal airway – 3 sizes –

size 3, 4 and 5.Proper size facemask – tight seal cover mouth

and nose.Laryngoscope with curved blade (Macintosh)

in which the bulbs works.Lubricant – with lignocaine gel


Endotrachel various sizes – prepare in 3 sizes – 7.5mm, 8.0mm and 8.5mm.

Stylet as guide for endotracheal tubeSyringe 20ml to inflate the cuff once the tube

is in place.Stethoscope to check correct placement of

the tube by listening for breath sound.Suction machine function, to remove

secretions.Plaster/string to anchor endotracheal tube at

the level of the patient teeth.


Preparation for Intubation


G.A. Machine


Breathing Circuit and CO2 Absorber


Preparation of drugs.Induction agent.

Injection Propofol 50 mgInjection Fentanyl100 mg

Muscle relaxant.Injection Sux (scoline)Injection Esmeron 60 mg


Reversal. Injection Atropine 1 mgInjection Neostigmine 2.5 mg

NSAID Injection Parecoxib 40 mg (Dynastat)Injection Dexamethasone 4 mg

AntibioticInjection Cefuroxime 1.5 gm


Preparation of Drugs


Preparation of Epidural


Preparation of patients Inform about the consent

consent for operation Consent for anaesthesia Consent for blood

Nil by mouth – to empty the stomach for 6 to 8 hours to prevent complication during intubations.

Give emotional support by listening patient express regarding operation. Answer all questions or any doubt so that patient understands and less worried.


Position of the patient – sniffing position / morning sniff position serve to align the oral, pharyngeal and laryngeal axis, so that the passage from the lip to the glottic opening is almost a straight line. This position permits better visualization of the glottis and vocal cord and allows easier passage of the endotracheal tube.

Ensure good intravenous line and patent.Vital sign taken as baseline data.


Attached all monitor such as SPO2 probemake sure proper position of SPO2 infrared

and photodetacted are parallel for better reading.

Blood Pressure cuff - proper size 2/3-circumference upper arm. ECG electrodes attached.

Put patient on warming device or warm blanket to prevent hypothermia.


Sitting Position for Epidural


The legs are allowed to hang over the edge of the bed with the feet supported by a stool.

The shoulders are “hunched” forward and the patient is encouraged to hug a pillow in towards the abdomen to provide anterior flexion of the spine.

This position helps to identify the midline of the spine and mark the desired lumbar


Technique.

Rapid sequence induction because patient had mass 5X5 cm in abdomen cavity.


Cricoid Pressure (Sellick’s Maneuver)

Is a method or preventing regurgitation of stomach contents into the larynx (wind pipe) during intubation and induction of general anesthesia .

Usually for emergency case and full stomach condition.




To perform Cricoid pressure

An assistant locate the position of the cricoids cartilage before induction.a. The cricoids cartilage is manually pushed back to occlude the esophagus.b. Use 3 fingers – thumb, index and middle finger

hold cricoids rings.c. Index finger apply firm pressure 30-40 Newton

backward or downward to the anteriolateral aspect as soon as anesthesia has been achieved.d. Only release pressure after endotracheal tube inflate and tube placement has been confirmed.


Advantages.

Cricoids pressure can protect the lung from aspiration of gastric content.

Can top up drugs and pain relief because done under GA + epidural.

Good quality of analgesia.


Disadvantage

1. Aspiration can occur if unproper cricoid pressure.

2. Slow awakening after G.A.

3. All general anesthesia complication can occur.


Complication:

Larynggospasm Bronchospasm Hypoxia Aspiration Pharyngitis. Laryngeal or Sub

Glottis Edema

Vocal cord paralysis Arytenoids Cartilage

Dislocation. Cauda equina

syndrome. Transient neurological

symptoms Arachnoiditis


Literature Review.

Book of anesthesia and uncommon diseases written by Katz / Benumuf / Kadis. 3rd Edition describes …. The technique of rapid sequences intubation outlined here has proved to be of great safety for patients at significant risk of aspiration.


Krivak et al Gynecol Oncol. 2001; 83:89–94. doi: 10.1006/gyno.2001.6334. [PubMed] describes …. therapy of uterine sarcomas remains surgery. Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) can be curative if disease was confined to the uterus with five-year survival approaching 50%

Literature Review.


General pre anaesthesia preparation for patient

Pre anaesthesia visit Nursing assessment Nursing assessment Physical Preparation Preparation on the day operation.


Preparation of theatre Preparation of induction room Preparation of Anaesthesia Machine Preparation of haemodynamic monitoring Preparation of OT table and light. Preparation Of Other Equipment

Suctions, Oxygen Deliver Scavenging Preparation Of Recovery Area. Temperature & Humidification


Receive patients from Airlock to O.R.

From arrival, greet patient to comfort the patient – checked patient according to the checklist


Air Lock

Care of patient


Pre

Apart from checklist, including:

1. Vital sign for data baseline taken

2. Keep all line safe and running well

3. Ensure all equipment for intubation are checked ,available and ready for used.


Intra

1. Ensure patient safety by locked the O.T. table at all time.

2. Avoid any potential injury during positioning. 3. No excessive abduct of the hand during surgery

avoid brachial plexus injury.4. Keep patient warm by warming mattress.5. Continuously monitor vital sign.6. Use warm fluid intravenously to prevent

hypothermia 7. Cover both eyes with eye pad.8. Monitoring MAC value more than 1 to prevent

awareness.


Post

1. Secured the patient airway especially during cleaning phase.

2. Assist the anesthetic confidently during the extubation ensure all the item are ready and functioning well to prevent complication e.g. hypoxia.

3. Observed patient vital sign at all time so that any complication can detect early.

4. Transfer patient from OT table to trolley safely using slider when allowed by anesthetic.

5. Documentation.


Advice On Discharge

Advised patient post GA 1. Turn head lateral if patient vomit.2. Not allowed oral and fluid intake until instructed by doctor.3. Observed and informed for bleeding and pain on operation site.

4. Noticed immediately if symptom of drug overdoses during infusion pethidine of epidural.


Nursing Care Plan - PRE OP

A.Aspiration due to nausea and vomiting before inductionObjective: To prevent aspiration during induction.Nursing intervention

1. Prepare MALES and difficult intubations item2. Makesure intravenous line patent for injection of drugs3. Suction function well to remove any secretions4. Insert oropharyngeal airway to maintain airway5. Preoxygenation 100% oxygen 15litre, 3 to 5 minutes via mask tight seal.6. Use technique rapid sequence induction .Applied proper cricoids pressure. Only release once confirmation of tube replacement are verified.Evaluation: Intubations are smooth with no complication.


PRE OPB.Anxiety due to operation

Objective: To reduced patient anxiety.Nursing intervention1. Encourage relatives to accompany patient to air lock.2. Give emotional support to patient by spend time talking to him so that he feel comfortable .3. Identify patient worried by asking and observed from patient face and try to overcome the worried.4. Informed him regarding GA.5. Makesure pre-med sedative T. Dormicum 7.5mg given on night and before send patient to O.T.6. Informed patient pain relief will be given after operation and will be monitored at recovery before send to ward.Evaluation: Patient less anxiety with haemodynamic stable


Nursing Care Plan - INTRA OP

A. Hipothermia due to long duration of operation – 4 hours.Objective: To prevent hypothermia.Nursing Intervention:1. Monitor vital sign especially temperature using nasal probe.2. Warm patient with warming device e.g. warming mattress.3. Used warm intravenous solution .4. Used warm irrigation for wash out along operation.5. Keep ot temperature within 18˚c to 22˚c.6. Avoid exposed other body parts except for surgery

Evaluation: Core body temperature within normal range 37˚c


INTRA OP

B.Potential injury due to supine positionObjective: To prevent any injury during operation and post opNursing Intervention:

1. Make sure O.T table always locked at all time avoid any movement to o.t table which effect surgery2. Armboard securely fixed avoid both hand fall down 3. No excessive abduct of left hand more than 90˚ avoid brachial plexus injury.4. Make sure no body parts outside the o.t table during supine position avoid patient fall down.5. Put pillow under both legs avoid nerves injury to the heels.

Evaluation: No nerve injury and other injury throughout operation and post op.


Nursing Care Plan - POST OP

A.Pain due to surgeryObjective: To reduced pain post operative.Nursing Intervention:

1. Acces severity of pain using visual analogue pain score2. Monitor vital sign especially blood pressure and heart rate

Blood pressure high and tachycardia shows patient in pain.3. Attend and listen to patient complaint of pain. Give pain

relief if patient complaint of pain.4. Teached patient on deep breathing exercise as divertional theraphy.5. Adviced patient avoid any rapid movement to the left hand and left thigh which can cause pain.

Evaluation: No complaint of pain from patient and pain score is zero.


Nursing Care Plan - POST OP

A.Pain due to surgeryObjective: To reduced pain post operative.Nursing Intervention:

1. Acces severity of pain using visual analogue pain score2. Monitor vital sign especially blood pressure and heart rate

Blood pressure high and tachycardia shows patient in pain.3. Attend and listen to patient complaint of pain. Give pain

relief if patient complaint of pain.4. Teached patient on deep breathing exercise as divertional theraphy.5. Adviced patient avoid any rapid movement to the left hand and left thigh which can cause pain.

Evaluation: No complaint of pain from patient and pain score is zero.


Discussion

Overall this case study I find that as an assistant we must have skilled, knowledgeable and always be prepared physical and mental incase if any problem arise.


Recommendation

Patients are often anxious about the diagnosis, the findings and outcome of the operation and about postoperative pain. Egbert et al 1964 describes Information and reassurance has been shown to reduce the patient’s anxiety and make it more manageable.


Conclusion

Combined general anaesthesia with epidural for patient under gone total abdominal hysterectomy bilateral Salpigo-oophorectomy very acceptable for this case study. Epidural pethidine post operation analgesic really working in this case study. She had minimized pain on two day post operation.


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Case Study Majri