The Operating Theatre Journal - Flipbook - Page 8
The post-anaesthetic care of a patient following impacted wisdom tooth extraction
Neeve Theobald-Smith
This essay was written as part of the assessment for a second year
recovery module as part of Canterbury Christ Church University BSc
Operating Department Practice Apprenticeship Course. Pain and PONV
management were assessed by alternate means thus are outside the
scope of this essay.
After 10 minutes patient X tolerated sips of water, demonstrating their
swallow re昀氀ex was restored. They were able to cough, showing their
cough re昀氀ex was working and they could manage their own secretions.
Patient X was also able to hold a conversation thus demonstrating a
patent airway.
This case study discusses the post anaesthetic care for an elective
American Society of Anaesthesiologists (2020) (ASA) grade I patient.
It describes how pharmacology of maintenance agents, fasting and
surgery can impact the patient in the post anaesthetic care unit
(PACU). As well as demonstrating safe practice, including oxygen use
and local anaesthetic (LA) dosage, while using a systematic approach
it will assess care delivered against national standards. Finally it will
detail a structured handover including a decision making tool ensuring
the patient is sent to a safe place following PACU.
Next the patient’s breathing was assessed following the RCUK (2021)
look, listen, feel technique. The RR on arrival was 12 breaths per minute
and the breaths were shallow, this was due to the decrease in tidal
volume caused by the maintenance agent propofol and also associated
with remifentanil. Scarth and Smith (2016) suggest an infusion of
propofol causes a decrease in tidal volume. Davison and Cottle (2010)
propose propofol causes a reduction in RR and tidal volume. After 10
minutes the RR increased to 14, then to 16 on discharge. The breaths
also became deeper. This shows that propofol was being metabolised by
the liver and kidneys (Sahinovic et al. 2018), allowing the tidal volume
to increase. Remifentanil is rapidly metabolised by the time the patient
is in PACU, therefore it does not impact breathing. Scarth and Smith
(2016) suggest the elimination half-life of remifentanil is 5-14 minutes.
Con昀椀dentiality is maintained in line with the Health and Care
Professions Council (HCPC)(2023) standards of pro昀椀ciency for Operating
Department Practitioners (ODPs) and also HCPC (2016) standards of
conduct, performance and ethics. Personal information that could
breech con昀椀dentiality and expose the identity of the patient, staff or
trust are not disclosed with pseudonym patient X used.
Following the removal of a size 6 nasotracheal tube by the anaesthetist
in theatre, patient X was transferred to PACU on a medium concentration
(MC) face mask with 8 L/ min oxygen from a portable oxygen
cylinder. Association of Anaesthetists (2021) recommends a tested
and functioning oxygen supply for transfer, meeting this standard.
According to Flexicare Group Ltd (2021) a 昀氀ow rate of 6-8 L/min the MC
mask delivers an oxygen concentration of 40%-50% dependent on the
patient’s tidal volume and respiratory rate. Monitoring for transfer met
standards of monitoring during anaesthesia and recovery (Association
of Anaesthetists, 2021) including non-invasive BP (NIBP), pulse oximetry
and a 3 lead electrocardiogram (ECG) with capnography not necessary
for transfer to PACU.
Handover to PACU was done following situation, background,
assessment, recommendations (SBAR) (National Health Service (NHS),
2021). This structured communication meets the HCPC (2023) standard
to communicate appropriately and effectively. It was handed over that
Patient X is 24 years of age, height 160cm, weight 63kg and average
build. Body mass index (BMI) 24.6, calculated using the NHS (2018) BMI
calculator, was in the healthy range.
A surgical handover was conducted by the scrub practitioner, stating
patient X underwent an impacted wisdom tooth extraction, two dental
packs were in place and absorbable sutures had been used. Wilfried
et al. (2014) state it is common to experience pain, oedema, and
trismus in PACU following this procedure. In line with Royal College of
Anaesthetists (RCoA)(2019) there was an anaesthetic handover. Patient
X received a total intravenous anaesthetic (TIVA). The maintenance
agents were propofol and remifentanil, paracetamol was used for
analgesia and ondansetron as an antiemetic. A paralysing agent was
not used for nasal intubation.
On arrival to PACU a systematic ABCDE approach (Resuscitation
Council United Kingdom (RCUK), 2021) was used to assess the patient.
Throughout PACU and on discharge the preoperative values were
referred to, identifying the normal but fasted values for the patient.
Blood pressure (BP) was 114/73 , oxygen saturation levels (SpO2) 98%,
respiratory rate (RR) 14 and heart rate (HR) 92.
Firstly the patients airway was assessed. The airway was patent, there
was misting seen in the MC facemask, there was no snoring nor was
the airway completely silent (RCUK, 2021). Simons and Pierce et al.
(2016) state propofol causes loss of airway patency due to increased
collapsibility of the upper airway muscles. Allman and Wilson (2015)
also propose propofol obtunds airway re昀氀exes meaning the ability to
manage secretions is impaired thus saliva and mucous can obstruct the
oropharynx. The patient’s mouth was suctioned on arrival removing
any secretions that could potentiality cause airway obstruction.
RCoA (2019) states capnography aids early detection of airway
obstruction and should be available in recovery. Capnography was
used to assess the patency of patient X’s airway, using a capnography
face mask (MEDICARE, 2023), therefore exceeding this standard of
care. The carbon dioxide waveform on the monitor was ‘top hat’
shaped. According to Cook et al. (2013) a top hat shape indicates a
clear unobstructed airway, meaning patient X’s airway was patent.
8
On arrival to PACU, the SpO2 was 99% on an 8 L/min MC face mask.
O’Driscoll (2017) recommends that SpO2 is kept at a target of 94-98% in
recovery, therefore meeting this standard. The SpO2 was 100% after 10
minutes so the oxygen was stepped down to 3 L/min via nasal cannula
to wean the patient off oxygen. SpO2 remained at 100% on discharge
on room air. O’Driscoll (2017) suggests oxygen is reduced in patients
with satisfactory oxygen saturations and then discontinued once the
saturations are maintained, therefore meeting this standard of care.
Circulation was then assessed. On arrival to PACU NIBP was 108/55,
Scarth and Smith (2016) explains propofol produces a 15-25% decrease in
BP. Goodchild and Serrao (2015) agree propofol causes cardiovascular
depression and hypotension. Kassam et al. (2011) explains propofol
causes hypotension due to the decrease in cardiac output and also
decreased peripheral vascular resistance. After 10 minutes the NIBP
increased to 111/61 as the propofol wore off and was metabolised by
the liver. On discharge the NIBP was 114/62.
The pulse and heart rate on arrival were 64 on the pulse oximeter
and ECG. The ECG shows a normal sinus rhythm (PerioperativeCPD.
com, 2023). Neal (2020) suggests propofol can cause bradycardia,
explaining the lower heart rate. After 10 minutes HR increased to 70 as
the propofol wore off, on discharge it was 74. Greig and Crabtree (2014)
maintain that bupivacaine containing adrenaline can cause tachycardia,
explaining the slight elevation of HR on discharge. The capillary re昀椀ll
time (CRT) was checked, peripherally it was 2 seconds, showing good
perfusion.
Normal 昀氀uid balance is disrupted by surgical fasting, so accurate 昀氀uid
assessment and management was needed (Watson and Austin, 2018).
Patient X last ate at 11pm the night before surgery and drank water
at 6am on the day of surgery. They were second on the theatre list
and arrived in PACU at around 12pm thus fasting for 13 hours. With an
average build and weighing 63kg the daily 昀氀uid requirement is 1701mls,
dividing this by 24 gives an hourly rate of 70.8mls. Multiplying this by
the 13 hours fasted shows a requirement of 920.4mls (NICE, 2017).
Patient X received 1 litre of Plasma-Lyte intraoperatively and sips of
water in PACU, meeting the replacement 昀氀uid requirement. Watson
and Austin (2018) propose that patients who have fasted for anaesthesia
have impaired regulation of 昀氀uid balance. A disturbance in regular 昀氀uid
balance elicits a physiological stress response which can lead to 昀氀uid
re-distribution.
Disability was assessed, including consciousness. This was reviewed
using the AVPU score (Romanelli and Farrell, 2022). On arrival patient
X was V on the AVPU scale, responding only when prompted by voice.
Propofol decreases consciousness levels, explaining the reduced
alertness (Pierre, 1999). After 10 minutes they were alert, responding to
commands and holding conversations. This shows that the maintenance
agent propofol was metabolised.
Disability includes toxins such as drugs, it needs to be con昀椀rmed a safe
dose of LA has been given. Patient X received 10mls of 0.25% Bupivacaine
which contains 2.5mg/ml of LA, meaning 25mg of LA was given. Peck,
Williams and Hill (2008) state the maximum dose for bupivacaine is
2mg/kg, patient X is 63kg therefore their maximum dose is 126mg, they
received 25mg meaning a safe dose of LA was given. Taylor and McLeod
(2020) agree with the maximum safe dose of bupivacaine and explore
LA toxicity.
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