The Operating Theatre Journal - Flipbook - Page 14
The Post-Anaesthesia Care of an Elective
Inguinal Hernia Repair Patient
Joanna Sobczyk Apprentice ODP Sa21
This case study was prepared as an Apprentice Operating Department
Practitioner in the second year of apprenticeship to an NHS trust as
part of a recovery module assessment at Canterbury Christ Church
University in 2022. Pain assessment and management were assessed
by other means thus do not feature in the case study below unless they
affect patient observations.
This case study will detail care in the post-anaesthesia care unit (PACU)
of an elective, adult patient undergoing herniorrhaphy under general
anaesthesia (GA). The aim of this study is to evaluate if the care
given met national standards. Principles of pharmacology, anatomy
and physiology related to this case will be included. The effect of
anaesthetic agents and the surgery on the patient will be explained
along with a safe administration of oxygen and a safe dosage of local
anaesthetic. A systematic assessment approach with 昀氀uid assessment
will be described. Finally, this case study will assess the decision-making
tools and handover of ongoing patient needs to the ward including
effective communication and collaboration between multidisciplinary
team members.
To comply with the standards of con昀椀dentiality (Health and Care
Professions Council (HCPC), 2016), all identi昀椀ers are anonymised and
the patient in this case study will be referred to by a pseudonym
George.
George (42, male), with a body mass index (BMI) of 27.7 (1.82m and
92kg) (National Health Service (NHS), 2022) and a classi昀椀cation as
overweight (National Institute for Health and Care Excellence (NICE),
2022), has no relevant medical history or allergies, does not smoke
and drinks alcohol occasionally. American Society of Anaesthesiologists
(ASA) (2020) classi昀椀es him as ASA I.
George’s baseline observations were taken on the day of surgery:
blood pressure (BP) 132/87mmHg, pulse rate (PR) 74 beats per minute
(bpm), oxygen saturation (SpO2) 99% on air, respiratory rate (RR) 14
breaths per minute (b/m), and temperature 36.9°C. George last ate
and drank 13 hours before arrival at the PACU. As all patients are at
risk of developing pressure ulcers (NICE, 2014), the Waterlow score was
used to assess George scoring 3, low risk (Waterlow, 2005).
George underwent surgery for an open right inguinal herniorrhaphy
under GA to repair an inguinal hernia, a condition in which abdominal
content protrudes through the abdominal wall and enters the inguinal
canal in the groin (Smith Jr, 2019). Coe昀椀eld and Feliciano (2013) and
Shah et al. (2013) point out urinary retention, wound infection, and
bleeding inside the incision as potential postoperative complications in
immediate recovery.
After surgery, breathing spontaneously but unresponsive, George was
transferred to the PACU. He had an i-gel® (Intersurgical, 2023) in situ,
with a T-bag® (M02ED, 2023), and was connected to the supplementary
oxygen cylinder in line with the Royal College of Anaesthetists (RCoA)
(2023) and 昀氀ow of 6l/min and 70% concentration (M02ED, 2023). The
supplement oxygen is used to prevent potential hypoxaemia because
of airway obstruction from reduced muscle tone and tidal volume
(TV) (Suzuki, 2020). High concentrations of oxygen impede breathing
by decreasing the hypoxic drive of respiratory stimulation (Lyons and
Kevin, 2021). The British Thoracic Society (BTS) (2019) recommends
oxygen concentrations of 35-40% to achieve a target saturation of 9498%. Moreover, the preferable standards of having the same monitoring
as being in theatre (Association of Anaesthetists, 2021) were not met as
George’s monitoring was disconnected during the transfer.
In the PACU, the oxygen was transferred to the wall supply and the
昀氀ow was reduced to 3l/min (44%) (Peyton et al., 2000). George was
connected to non-invasive BP, pulse oximetry, electrocardiogram (ECG),
and, as having an airway in situ, capnography monitoring, thus meeting
the monitoring standards (Association of Anaesthetists, 2021). Following
SBAR (situation, background, assessment, and recommendations) (NHS,
2010), a structured handover was given by the anaesthetist and the
scrub practitioner.
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George had propofol, fentanyl and rocuronium at induction of
anaesthesia. His airway was secured with an i-gel®, a supraglottic
airway device designed for fasted patients (Al Shaikh and Stacey,
2019). Ondansetron and dexamethasone were given for the prevention
of postoperative nausea and vomiting (PONV), and cefuroxime as
antibiotic prophylaxis (Freedman et al., 2022). Further, paracetamol
(1g), diclofenac (75mg) and morphine (10mg) were administered
intraoperatively as pain management. The anaesthesia was maintained
with sevo昀氀urane, oxygen, and air. Sugammadex was used to reverse
neuromuscular blockade induced by rocuronium (Scarth and Smith,
2022). The incision was closed with dissolvable sutures, skin glue and
no dressing. The wound was in昀椀ltrated by the surgeon with 30ml of
0.25% levobupivacaine. 1ml of 0.25% levobupivacaine equals 2.5mg/ml
giving a total of 75mg in 30ml (Joint Formulary Committee (JFC), 2022).
A maximum dose of levobupivacaine at any time is 150mg (JFC, 2022;
Peck and Harris, 2021) therefore George received a safe dose of local
anaesthetic.
The ABCDE assessment (Resuscitation Council (RCUK), 2019) was used
to assess George as he was affected by sevo昀氀urane, the anaesthetic
maintenance agent. Fluid, assessment were added while caring for
George, however pain and PONV are not discussed here unless affecting
his observations.
Sevo昀氀urane affects the airway by relaxing the pharyngeal muscle,
relaxing the tongue muscle with the consequence of its posterior
displacement, disabling protective re昀氀exes to cough and clear
secretions from the airway (Davidson and Cottle, 2010). George’s
airway was assessed for patency as emerging from anaesthesia may
have contributed to the displacement of the airway from the right
place and obstruction (Al-Shaikh and Stacey, 2019). The T-bag® was
in昀氀ating and de昀氀ating in a regular rhythm with a mist in the i-gel®
stem. The capnography trace, in the shape of ‘top hats’, indicated an
unobstructed airway (Cook et al., 2013). No signs of the use of the
accessory muscles (tracheal tug) or abnormal noises suggested no
airway obstruction or breathing struggle (Thompson et al., 2019).
Breathing is affected by sevo昀氀urane with a dose-dependent decrease
in TV and depression of normal re昀氀exes to stimulate breathing in
response to hypoxaemia (Thompson et al., 2019). George’s breathing
was assessed by ‘look, listen, and feel’ (Baid et al.,2016). The SpO2
98% was within the target saturation of 94-98% (BTS, 2019). A pulse
oximeter is essential to monitor hypoxaemia but does not indicate
adequate ventilation (Elliot and Baird, 2019). 16 regular b/m (RR),
counted for one minute with the practitioner’s hand on George’s chest,
corresponded to the capnography monitoring. Shallower breaths and
昀氀atter capnography waveform indicated reduced TV (Sulivan, 2020).
There were no abnormal sounds or other signs of respiratory distress
(see-saw chest abdomen movement or use of the accessory muscles).
Ef昀椀cient breathing and ventilation indicate adequate oxygenation
(Craig and Hat昀椀eld, 2021).
To maintain adequate oxygenation, there must be suf昀椀cient circulation
for blood to carry oxygen to tissues (Maguire, 1999). The cardiovascular
system is compromised by sevo昀氀urane in a dose-related decrease in
myocardial contractility and systemic vascular resistance, resulting in
decreased BP and mean arterial pressure (MAP) (Davidson and Cottle,
2010). George’s BP was 119/72mmHg (MAP90). His heart rate (HR)
measured by the ECG was 51. George was in a normal sinus rhythm
(Hampton and Adlam, 2019) and there were no abnormalities in the
ECG indicating complications or local anaesthetic toxicity (Hill et
al., 2009). The PR detected by palpation for one minute was 50bmp,
regular, strong and within the acceptable range of 50-80bpm for
patients in recovery (Craig and Hat昀椀eld, 2021). Decreased BP is caused
by depression of the cardiac regulatory centre by sevo昀氀urane and
potential hypovolaemia attributable to perioperative fasting (Maguire,
1999). George’s skin colour and capillary re昀椀ll