The Operating Theatre Journal - Flipbook - Page 15
Disability assesses the brain and level of consciousness. Sevo昀氀urane
affects the central nervous system inducing a deep plane of GA thus
unconsciousness (Yentis et al., 2019). George was assessed using a local
0-4 sedation score (0=awake and alert, 1=slightly drowsy, 2=moderately
drowsy but can talk when roused, 3=very drowsy and mumbling,
4=unconscious and unrousable). George’s score (4) suggested he was
still under the signi昀椀cant in昀氀uence of sevo昀氀urane.
For exposure, George was visually examined from head to toe. The
cannula in his left-dorsal hand had no signs of extravasation or tissue
damage. The line was clear, and the drip was running freely indicating
patency (Craig and Hat昀椀eld, 2021). To maintain George’s dignity and
respect his privacy (HCPC, 2016), the curtains around the bed were
closed before exposing George to check his surgical site and pressure
areas. The wound, a 3-inch transversal incision on the right inguinal
region, was clean and dry, with no signs of fresh blood or secretion
coming through (Craig and Hat昀椀eld, 2021). The pressure areas were
intact. George was wearing anti-embolic stockings as per VTE
prophylaxis (NICE, 2019). As George was covered with one cotton sheet
and only one blanket, the second blanket was added to keep him warm
and prevent hypothermia (NICE, 2016). George’s temperature (36.2°C)
was measured with a non-contact temporal thermometer HuBDIC
(2012) which does not comply with NICE guidelines (2016) as it does not
publish an estimation of core temperature.
Fasting and 昀氀uid shifting into the third space due to stress response to
surgery can cause hypovolaemia (Freedman et al., 2022). George’s daily
昀氀uid requirement was calculated as 2760ml (92kgx30ml) (NICE, 2017).
2760ml:24h=115ml/h which multiplied by 13 hours of fasting = 1495ml of
昀氀uid de昀椀cit.1000ml of Hartmann’s solution was administered in theatre
and the second 1000ml was running in the PACU to be administered
until George starts to eat and drink. The 昀氀uid assessment indicated
that George’s ongoing 昀氀uid requirements were met.
The secretion of sevo昀氀urane is via the lungs (Scarth and Smith, 2022).
George was exhaling sevo昀氀urane and after 10 minutes in the PACU,
opened his eyes. He was told he was waking up in recovery after his
procedure. He was responsive to commands to open his mouth and was
regaining consciousness and protective airway re昀氀exes. The i-gel® was
removed uneventfully and replaced with a Hudson mask with a 昀氀ow of
6l/min (40%) supplementary oxygen (Wagstaff and Soni, 2007).
George could speak, cough and swallow indicating a return of muscle
tone, protective re昀氀exes, and a patent airway.
RR was counted as 14 regular b/m with good depth and quality showing
increased TV. Steam in the mask, SpO2 of 98% and absence of signs
of cyanosis, abnormal sounds or use of accessory muscle indicated
effective breathing.
Increased BP 128/80mmHg (MAP97) and PR 58bpm indicated an increase
in myocardial resistance and in systemic vascular resistance.
George could answer the questions but was initially sleepy and
disorientated (sedation score 2) as expected when emerging from
anaesthesia (Craig and Hat昀椀eld, 2021). No signs of muscle weakness and
respiratory distress suggested no postoperative residual curarization
(PORC) occurred (Martin et al., 2020; Freedman et al., 2022).
George’s wound was dry and clean. Adjusting his position, George
was able to relieve his pressure areas. When asked, he stated he was
comfortable and warm. His temperature was 36.4°C. He denied being
in pain or nauseous. As George accepted drinking water and tolerated
this, his IV 昀氀uids were disconnected.
George stayed stable and was systematically assessed using the ABCDE
approach. All 昀椀ndings during his stay in the PACU were appropriately
documented (HCPC, 2014).
After a further 15 minutes, having SpO2 100%, George was weaned from
oxygen by taking his mask off to see if he was able to maintain his SpO2
within 94-98% on air (BTS, 2019) which was successful.
After one hour in the PACU, with RR 14b/m, SpO2 98% on air, BP
121/78mmHg (MAP 96), PR 62bpm, temperature 36.7°C and being alert
(sedation score 0), George met local and national discharge criteria
from recovery (Association of Anaesthetists of Great Britain and
Ireland (AAGBI), 2013; RCoA, 2019) and his National Early Warning Score
(NEWS2) was calculated as 0, requiring continued routine monitoring
minimum every 12 hours (Royal College of Physicians, 2017). With no
pain or PONV, it was safe to discharge George to the ward.
As per RCoA (2023), George was handed over to the ward by using a
structured handover (SBAR). This included medical history, procedure,
anaesthesia, and drugs used (fentanyl, propofol, rocuronium at
induction, then dexamethasone, ondansetron, cefuroxime, morphine
(10mg), paracetamol (1g), diclofenac (75mg), sugammadex, and 30ml
of levobupivacaine 0.25% surgically). It was communicated the incision
was closed with dissolvable sutures, skin glue and no dressing. The
wound was clean and dry. George had a total of 1500ml of Hartmann’s
administrated and had about 200ml of water to drink but had not
voided yet. His observations were stable in recovery, he did not have
pain or PONV and was comfortable. As for recommendations, the
next dose of paracetamol was at 5pm, and regular, as-required (40%
oxygen, cyclizine, ondansetron and oral morphine) and take-home
(dihydrocodeine) medication had been prescribed. George could eat
and drink and be discharged home after passing urine and having stable
observations (SpO2 >94%, systolic BP >90mmHg and HR>50bpm). George
was informed about potential urinary retention and transient femoral
nerve palsy with leg weakness and buckling knee (Shah et al., 2013;
Ghani et al., 2013). George was advised to put pressure on the wound
when coughing and not to drive for two weeks as per the surgeon’s
instructions. Wishing George all the best, he was left under the care
of the ward staff.
This case study has described and evaluated the post-anaesthesia
care of an elective inguinal hernia repair, including monitoring, the
systematic approach in patient assessment, safe oxygen administration,
principles of pharmacology and changes in patient observation during
recovery from anaesthesia. The national standards in this case study
were met during recovery, discharge, and handover of the patient,
however, the standards of monitoring during the patient transfer from
the theatre could be improved depending on the journey length.
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Anaesthesia, Critical Care and Peri-Operative Medicine. 5th edn.
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American Society of Anaesthesiologists (2020) ASA Physical Status
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Coe昀椀eld, R.L. and Feliciano, D.V. (2013) ‘Inguinal hernia repair’, in
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Ghani, K.R., McMillian, R. and Paterson-Brown, S. (2002) ‘Transient
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December
2023
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