Awareness of the choice of anaesthetic technique and care plan by the anaesthetist has an important implication not only from pre-operative phase but for the postoperative outcome and recovery. The prerequisite for the clinical effectiveness, evaluation and success of any anaesthetic techniques and patient’s care plan start from the multidisciplinary collaboration team framework (Malviya et al 2011). This is embodied with a comprehensive implementation of guidelines to the agreed policies and procedures of the Local Trust (UHNM C04) in lined with the national policies of which defines the author’s role within the multidisciplinary team approach.
In this case study, the author will critically analyse and evaluate the anaesthetic care delivered to the patient in relation to his co-morbidities and how these affects the values enclosed in the new caring vision for nurses and are: care, compassion, competence, communication, courage and commitment – the six Cs (Department of Health and NHS Commissioning Board 2012).
In accordance with the Nursing and Midwifery Council code of conduct (NMC 2015) and Data Protection Act (2014) the patient will be referred to as Mr Y to protect his confidentiality. He was a 72 year old patient who was experiencing a long history of hip pain which was affecting his activity level. He was scheduled for elective total hip replacement under spinal anaesthesia. His pre-existing co-morbidities consisted of hypertension, controlled diabetes mellitus and gastro- oesophageal reflux disease. He had no known drug allergies and weighs 80 kilograms.
All of his diagnostic laboratory tests were carried out and clinic visits reviewed as per recommendation by the National Institute of Healthcare and Clinical Excellence (NICE 2010). Kumar et al (2013) mentioned that the preoperative assessment is a significant starting point to formulate effective anaesthetic plan therefore ensuring the patient will be fully informed about the procedure and warrant patient’s compliance towards recovery.
Mr. Y was placed into an enhance recovery care pathway programme of the Local Trust. The Quality and Service Improvement Tools and Institute and Innovation and Improvement (2013) stated that a planned care pathway enhances the quality of care in a number of ways. This includes less stress which can lead to patient’s quicker recovery, enhance their experience, improve clinical process and augment efficiency and productivity of the hospital.
On the day of surgery, Mr. Y was seen by the surgeon and anaesthetist. He was given a chance to ask for any additional questions and they were addressed accordingly. The WHO form is a comprehensive checklist that gives the team necessary information about the patient. The WHO checklist is part of the consent form which is signed by both patient and surgeon, and also confirms the site of operation marked any medical histories, allergies, infection control issues, and recent observations done on the ward. Upon arrival at the anaesthetic room, the author introduced themselves and commenced the checklist on the WHO confirming with the patient, his date of birth, that he had a clear understanding of procedure, time last eaten and drank and if he had any dentures in place or loose teeth, once satisfied the author then escorted the patient to the anaesthetic room. Those gestures will also establish rapport that is critical for building loyalty, trust and confidence to Mr. Y (Barkley 2015). Barkley (2015) added that the positive partnership with patient has a great impact on their outcome and builds credibility and sends the message “we care” leading to a positive case management outcome.
On initial examination Mr. Y’s baseline observations were the following: Blood pressure- 170/90, Heart rate- 72bpm, Respiratory rate- 14bpm, Oxygenation saturation on 21%- 96%, Temperature- 36.8C and Blood sugar: 10.2 mmols. The anaesthetist examined Mr. Y’s following the American Society of Anaesthesiologists Grades and evaluated him as Grade 2 which implies no functional limitation and well controlled disease of one body system (Henry 2012). His airway assessment was assessed with Mallampati score of 2, which indicates that airway management would not be difficult (Joyner 2015). The author believes in the importance of this scoring as this could be better grading outcome in weighing the incidence of intra and postoperative complications during surgery.
One of Mr. Y co-morbidities was hypertension and this had an implication during anaesthesia (James et al 2011). Hypertension is a common medical condition and is often asymptomatic (Mayell 2006). However, the assessment should include related illnesses to determine the extent of hypertensive end organ damage therefore risk in anaesthesia (Anaesthesia UK 2006). Moreover, this could determine the type of anaesthetic techniques and allows the management of drugs more safely during anaesthesia. Mr. Y was also known to be a diabetic that was controlled by diet and medication. Diabetes mellitus is an endocrine disease that can be associated with significant peri-operative morbidity and mortality (Giquel et al 2012). The major risk factors associated include cardiovascular dysfunction, renal insufficiency, joint collagen tissue abnormalities, and neuropathies, all of which influences the effect of anaesthethesia (Giquel et al 2012). As to the author’s role, it was critical to recognise those disorders and when indicated he must be aware of the appropriate investigation and management such as to avoid harmful hypoglycaemia and persistence of hypertension. The author believes that awareness of risks through thorough evaluation of the patient also helps to identify potential devastating consequences. A thorough discussion had been held between the anaesthetist and Mr. Y previously on the ward as to what were the benefits and risks of anaesthesia considering his past medical histories of hypertension, diabetes mellitus and oesophageal reflux. The author observed that anaesthetist considers many factors such as patient’s age, medical allergies, weight, general health and social well-being when deciding of what anaesthetic to use. In Mr Y’s case, the anaesthetist fully discussed the pros and cons of the use of spinal anaesthesia and general anaesthesia in THR. This was to ascertain their preferences and help them to make a choice that was best for them (RCoA 2008). Jones et al (2014) also added that collaborative decision making with clinicians and the patients play an integral part throughout the patient’s journey. Based on his multiple co-morbidities and considering his post-operative outcome, the anaesthetist believed that the use of spinal anaesthesia was the anaesthetic choice. Spinal anaesthesia was associated with less significant complications compared to general anaesthesia. Neuman and colleagues (2014) conducted the near-far matched analysis and showed that regional anaesthesia was associated with a 0.6 day shorter length of stay than general anaesthesia. At the end, it was ajoint decision and Mr. Y consented to it after his own evaluation of the risks and benefits of the proposed procedure. Total hip replacement (THR) is a common, painful procedure requiring a good quality of pain control post operatively to facilitate best outcomes including reduction in length of stay and chronic pain post-surgery. The increasing pressure on resource utilisation, the quality and type of anaesthesia and postoperative pain relief can have a significant impact on the ability to meet rehabilitation goals (McCartney et al 2013). It is stated that spinal anaesthesia has gained prominence with several studies leading many anaesthetists and surgeons to take this information, demonstrating its superiority over general anaesthesia in terms of morbidity and mortality giving another anaesthetic option for the patient. Recent epidemiological studies have continued to reinforce those datas indicating a reduction in risk of morbidity and mortality with the use of spinal anaesthesia (Memtsoudis et al 2013). The author appreciated the findings as to what was the best method of anaesthesia and postoperative analgesia for patients undergoing total hip replacement, however;, the author personally believes that spinal anaesthesia is more favourable than general anaesthesia weighing its risks and benefits in Mr Y’s case.
Leaver (2012) explains that spinal anaesthesia (SA) is produced by injection of a measured anaesthetic drug into the cerebrospinal fluid and no specific dose adjustments are normally needed when performing it in the elderly. He added, this may produce significant hypotension due to a reduction in systemic vascular resistance secondary to concomitant sympathetic blockade. In recent studies, SA found to have a reduced risk for post-operative deep venous thrombosis, post-acute postoperative confusion, shortened operative time and less blood loss (Kettner et al 2011). Furthermore, it decreases peri-operative cardiac ischaemic incidents, postoperative hypoxic episodes and provides proper post-operative pain control (At-tari et al 2011). It also gives advantage to diabetic patient as they can return to their normal diet soon after the operation (Werrett 2006).
The author believes that spinal anaesthesia is not without risk. Although rare, risks include potential spinal haematoma, infection or abscess in recent practice (Brull et al 2007). The most common complications are short term (RCoA 2015). They are post dural puncture headache of which nearly none existing with the use of pencil point spinal needle in THR, total spinal block and transient neurological deficits (RCoA 2015 ). Conversely, general anaesthesia (GA) can induce physiologic fluctuations such as reducing cardiac output and systemic vascular resistance resulting to hypotension due to the use of volatile anaesthetic and intravenous agents and mild hypothermia of which some requires active interventions (Bryant and Bromhead 2009). In such circumstances these will result to ischaemic consequences and triples the risk of morbid myocardial outcomes, impaired coagulations, reduced resistance to infections and prolongs recovery (Feinstein et al 2013) and length of stay and chronic pain post-surgery