The Operating Theatre Journal - Journal - Page 22
A case study detailing the postoperative
recovery of an elective patient
This case study encountered on placement was
written as part of the assessment for a year 2
post anaesthetic care module forming part of
the Operating Department Practice BSc Hons
course at Canterbury Christ Church University
in 2022. Pain assessment and management
were assessed by other means and so do not
feature in the case study below unless they
affect patient observations.
This case study will illustrate the
postoperative recovery of an elective surgical
patient, examining the in昀氀uence of anatomy,
physiology and pharmacology on the post
anaesthetic recovery. A systematic approach
has been used to ensure the ef昀椀cient and
thorough assessment and handover of the
patient.
Upon
arrival
pulse
oximeter
with
plethysmograph, non-invasive blood pressure
monitoring (NIBP), 3 lead electrocardiogram
(ECG) and capnography were applied
(Association of Anaesthetists, 2021). A
detailed handover was given from both the
scrub practitioner and the anaesthetist who
stayed until the patient was fully connected
and the recovery practitioner was happy
(RCoA, 2019). Handover was given using the
SBAR communication tool (NHS England,
2021) which uses a standardised structure
to relay a patient’s situation, background,
assessment and recommendations. The use
of a structured handover ensures an ef昀椀cient
exchange of information which meets RCoA
(2023) standards.
This optimises communication and facilitates
early recognition of complications or
deterioration, supporting safe patient care
throughout admission (Smith and Bowden,
2017).
All care given will be evaluated
against relevant national standards and
optimal practice highlighted. To maintain
con昀椀dentiality (Health and Care Professions
Council (HCPC) 2016), all demographics have
been altered and a pseudonym has been used
throughout.
Upon induction, Tony was given 100mcg
fentanyl,
propofol,
4mg
ondansetron
and dexamethasone. Intraoperatively, 1g
paracetamol and 75mg diclofenac were
administered. Sevo昀氀urane was used as a
maintenance agent and was delivered in a
combination of oxygen and air. As per British
Thoracic Society (BTS) (O’Driscoll et al., 2017)
supplementary O2 via nasal cannula was
prescribed if needed, to maintain saturations
above 94%, until fully recovered.
Tony was a 21-year-old male, undergoing
the removal of 2 screws following an open
reduction internal 昀椀xation (ORIF) of an ankle
fracture. The postoperative risks in the post
anaesthetic care unit (PACU), associated
with orthopaedic surgery include bleeding,
neurovascular damage and pain (McLatchie et
al., 2022).
Pro re nata ondansetron, al昀椀ne and naloxone,
and regular paracetamol and ibuprofen was
prescribed. 10mls of 0.5% Levobupivacaine
which equates to 50mg was in昀椀ltrated to
the wound. This is within the maximum
recommended single dose of 150mg (Peck and
Harris, 2021).
Tony was an American Society of
Anesthesiologists (ASA) (2020) grade 1
patient. Weighing 76kg and 176cm tall, Tony
was classi昀椀ed as a healthy weight with a body
mass index (BMI) of 24.5 (National Health
Service (NHS) 2018). On the morning of surgery
Tony’s preoperative observations reported a
respiratory rate (RR) of 16, oxygen saturation
(SpO2) 98% on room air, blood pressure (BP)
121/71, heart rate (HR) 85 and a temperature
of 37.2℃ taken on a Genius™ 3 Tympanic
thermometer (Cardinal Health, 2021). This
thermometer had been adjusted to display
core temperature to meet the recommended
standard (National Institute for Health and
Care Excellence (NICE) 2016).
Resuscitation
Council
United
Kingdom
(RCUK) (2023) advocate the use of the
Airway, Breathing, Circulation, Disability and
Exposure (ABCDE) approach to thoroughly
assess patients, treatment and interventions.
It is imperative for good patient care that
a 昀氀uid assessment is carried out and that
reassessment is completed by the care
provider (NICE, 2017). This is especially
prudent for patients in PACU who may have
been fasted for an extended amount of time.
Tony was transferred into recovery semirecumbent on a trolley with a size 5 laryngeal
mask airway (LMA) and T-bag® (Tele昀氀ex,
2019) in situ, delivering a 70% oxygen (O2)
concentration using 6l/min from a portable
O2 cylinder. This is an excessive oxygen
concentration which could lead to hyperoxia
(Suzuki, 2020). In hindsight, 3l/min delivering
a 50% concentration O2 or less would be
preferable.
Tony was transferred to PACU with no
monitoring which is contradictory of the
Royal College of Anaesthetists (RCoA,
2019) guidelines. RCoA (2023) does state
that a minor interruption in monitoring is
acceptable, but only if the patient has been
transferred from a theatre directly adjacent to
PACU. As this transfer required a walk down
a corridor, continuous monitoring could have
been maintained.
22
Misting in the LMA was indicative of a clear
airway without a partial or total obstruction
(Smedley
and
Nicholas-Holley,
2022).
Capnography was continuously used to con昀椀rm
airway patency by displaying a castle shaped
end-tidal carbon dioxide (EtCO2) waveform,
until consciousness returned and the LMA
removed (Association of Anaesthetists, 2021).
The LMA was removed after 16 minutes
and replaced with a medium concentration
facemask without capnography, delivering a
40% concentration of O2 on 6l/min (Flexicare,
2021).
Sevo昀氀urane relaxes the pharyngeal muscles
and causes impairment in airway re昀氀exes in
the early stages of recovery (Ip and Gan, 2022).
As the gas is eliminated patients’ protective
re昀氀exes return. Although Tony was not talking
in full sentences immediately, he was able to
provide short answers to questions regarding
pain and nausea, and no rattling was noted.
This indicated a clear airway free of secretions
which Tony was able to protect himself by
coughing (RCUK, 2023).
THE OPERATING THEATRE JOURNAL
On arrival Tony’s SpO2 was 100% with
additional supplementary oxygen being
delivered via the LMA to avoid hypoxia.
Sevo昀氀urane blunts the ventilatory response to
hypercapnia (Chambers, Huang and Matthews,
2019) and causes respiratory depression which
continues to affect the patient until it is fully
eliminated via the lungs (Newton, Turton and
Corrin, 2022). A reduction in the depth and
rate of breathing was noted upon arrival which
improved as the volatile agent was expelled
from his system. Regular, quiet, and equal
bilateral chest rises were evident, with no
apparent abdominal breathing. Initial RR was
11 and increased to 14 once awake, 15 upon
discharge. Capnography was used to visualise
breathing patterns via a waveform (Rommie
and Duckworth, 2017).
This aids in establishing the ef昀椀ciency of
ventilation in patients receiving supplementary
oxygen (Foran and Wilks, 2021). A normal,
rounded rectangle or castle-shaped waveform
was seen throughout. Following the removal
of the LMA, Tony maintained SpO2 of 99%
on 6l/min O2, delivered at a concentration
of approximately 40% through a medium
concentration facemask (Flexicare, 2021).
After 15 minutes the facemask was removed
and Tony was able to maintain saturations
of >98% on room air until discharge when
the saturation probe was removed. When
transferred to the post-surgical ward Tony
was talking in full sentences and was able to
interact with the recovery practitioners with
no issue or concerns.
Sevo昀氀urane decreases systemic vascular
resistance (SVR), consequently reducing BP
and cardiac output (CO) (Edgington, Muco and
Maani, 2022). The impact of which is dependant
upon minimum alveolar concentration (MAC)
values and exacerbated by clinical condition
(Eis and Kramer, 2022). Tony arrived in sinus
rhythm and no other arrhythmias were noted
during his admission (Sandhu, 2022). Initial BP
and HR readings of 92/46 and 75 are re昀氀ective
of the reduction in SVR. These improved
after 15 minutes, increasing to 108/73 and
77 as the inhalation agent was eliminated.
Recordings of 133/69 and 83 were noted once
fully recovered.
A tourniquet time of 16 minutes and minimal
blood loss was documented. Tourniquets
ensure a bloodless operating 昀椀eld but are
associated with risks of nerve and skin damage
as well as pain (Vaughan et al., 2017). Essential
checks for signs of neurovascular compromise
were performed at regular intervals to assess
the sensation, movement, colour, warmth and
capillary re昀椀ll time (CRT) of the extremity.
Distal CRT remained