NRSG370 Clinical Integration: Specialty Practice 3 : Essay Fountain

Question:

Case Study – Perioperative

Mrs. Jane Austin is a 59-year-old woman admitted to the operating theatre for a laparoscopic cholecystectomy under general anaesthetic following a diagnosis of cholelithiasis and cholecystitis.

Mrs. Austin has a past medical history of hyperlipidaemia, hypertension, a body mass index of 28 and is a smoker. She is compliant with her regular medications Lipitor and Perindopril, and her blood pressure is well controlled.

Emergency department assessment (pre-operative):

Mrs. Austin presented to the emergency department following several bouts of severe right upper quadrant abdominal pain associated with uncontrolled nausea and vomiting. On examination she was tachycardic, febrile (elevated c-reactive protein) and complained of right upper quadrant tenderness on palpation. Mrs. Austin also complains of a recent intolerance to fatty foods, resulting in nausea when ingested. A duel diagnosis of cholelithiasis and cholecystitis was made via ultrasound. A pre-operative chest X-ray is clear.

Post-anaesthetic recovery room (PACU):

You are working in the PACU and receive Mrs. Austin following her surgery (laparoscopic cholecystectomy). The anaesthetist reports the patient had some mild haemodynamic instability during insufflation and maintenance of pneumoperitoneum, and that the procedure was slightly longer than usual because the surgeon had difficulty visualising the common bile duct due to the patient’s weight.

 

Answer:

Consider the patient situation- This case study involves a 59 year old female patient, Mrs. Jane Austin who is currently in the operation theatre for a laparoscopic cholecystectomy. Her current medications comprise of Lipitor and Perindopril. She had been admitted to the emergency department after she reported severe abdominal pain in the right upper quadrant, in addition to signs and symptoms of vomiting and nausea. Reports from the comprehensive health assessment confirmed the presence of tachycardia, fever and tenderness on palpation. In addition, she is also intolerant to fatty food and ultrasound examination revealed a dual diagnosis of cholelithiasis and cholecystitis. At the time of surgery, she reported moderate hemodynamic instability during pneumoperitoneum and insufflation and the operation took longer time, than normal. This was due to the heavy weight of the patient that made it difficult for the surgeon to visualise the bile duct.

Collect cues/ information- Mrs. Jane Austin has a medical history of high blood pressure, and hyperlipidaemia. This indicates that the blood has a high content of lipids or fats such as, triglycerides and cholesterol, which in turn have resulted in deposition of fats on the arterial walls, and have increased the blood pressure (Navar-Boggan et al., 2015). In addition, the patient also has a body mass index of 28, thereby indicating that she was overweight. Furthermore, she was also an active smoker. On assessing the vital signs, it was found that the respiratory rate was 28, blood pressure was 125/70 and pulse was 115 beats/min. Research evidences suggest that increase in heart rate is correlated with an elevation in blood pressure and also increases the risk of all-cause mortality in the patient (Yaghootkar et al., 2016). Furthermore, her smoking habits might have narrowed down the arteries and hardened the walls, thus increasing the likelihood of the blood to clot during circulation, thereby increasing blood pressure (Leone, 2015). While determining her level of consciousness, the patient was found to be alert and awake and reported a pain sensation at the tip of her shoulder of severity 6/10. Furthermore, upon auscultation, there were no bowel sounds and the airways was found to be clear. Moreover, the dual diagnosis of cholelithiasis can also be accredited to the presence of high cholesterol in the bile, and the lack of sufficient bile salts (Tazuma et al., 2017).

 

Process information- A respiratory rate of 28 breaths/minute, in comparison to the normal rate of 12-25 breaths/minute, provided evidence for the presence of tachypnea. This condition suggested that the patient reported signs of abnormally quick breathing and this can be attributed to her smoking habits (Park & Khattar, 2019). Prolonged smoking resulted in poor airflow and also made it difficult to breathe out completely, thus causing rapid breathing. Furthermore, the lung tissues might have also broken down due to smoking, eventually causing tachypnoea. In addition, a pulse of 115 beats/min was also higher than the normal value of 60-100 beats/min, thereby confirming tachycardia. This can be accredited to the presence of high cholesterol in the blood vessels that clogged up the arteries, supplying blood to the heart, thus increasing the likelihood of Mrs. Jane to suffer from stroke or heart attack (Pham, Shih, & Jucan, 2018). Her body temperature was 37.5° C, slightly above the normal temperature of 37° C, thus indicating low-grade fever. This can be accredited to the fact that inflammation of the gallbladder owing to the presence of a gallstone that obstructed the cystic duct caused problems in the breakdown of fats for digestion. Hence, presence of fever indicated inflammation in the gallbladder (Deshmukh, Rath, Reddy & Naresh, 2018).

Moreover, 89% SpO2 on RA suggested poor oxygen saturation and also indicated that she might be suffering from hypoxemia. In a healthy adult, oxygen saturation level generally varies between 96-99%, and refers to the fraction of haemoglobin that is oxygen saturated, in relation to the total haemoglobin present in the bloodstream. 89% SpO2 suggested that there was deficiency of oxygen in the arterial blood that eventually caused post-operative hypoxemia (Collins, Rudenski, Gibson, Howard & O’Driscoll, 2015). Elevated level of C-reactive protein also provided evidence for the presence of inflammation that be an indication for infection. In addition, high level of C-reactive protein also indicated that there occurred inflammation in the patient’s arteries, thus increasing her risk of suffering a heart attack (Shrivastava, Singh, Raizada & Singh, 2015).

 

Identify problem/issue- On analysing the presenting complaints and symptoms of the patient, it can be suggested that he is overweight that has created problem at the time of surgery. Furthermore, the presence of hemodynamic instability suggests that there was perfusion failure, which was manifested by signs of hypotension, abnormal heart rhythm and irregular respiration rate (Giesinger & McNamara, 2016). Therefore, hemodynamic instability occurred due to unstable and abnormal blood pressure, which can be accredited to the fact that although the patient had a history of hypertension, her vital signs suggested hypotension. This resulted in insufficient flow of blood to the organs and also led to shortness of breath (Haase-Fielitz et al., 2017).

Establish goals- The primary objective of this care plan would be to enhance the hemodynamic status of the patient. In addition, two other goals of the care plan are restoring her breathing rate and blood pressure to normal, within the next 24 hours.

Take action- With the aim of addressing the irregular blood pressure of the patient, the treatment will primarily rely on the process of volume resuscitation. It has often been found that loss of fluid from the extracellular space results in volume depletion and often causes acute life-threatening intravascular loss of volume, thus calling for the need of resuscitation for maintaining tissue perfusion. This resuscitation will be initiated at a rate of 150-200mL/hr, based on the patient’s volume status and colloid will be used for the purpose. This can be accredited to the fact that colloid molecules have larger weight and have oncotic plasma pressure that is comparable to natural plasma proteins (Bakes et al., 2016). Hence, the colloids will remain in the intravascular space and will thereby support the circulating volume, in contrast to crystalloids, which have been found to create extravascular shift, thus triggering interstitial and pulmonary oedema (Driessen et al., 2016). In addition, the hemodynamic stability of the patient will also be maintained by administration of a vasopressor such as, norepinephrine. Also referred to as anti-hypotensive agent, vasopressors will increase the cardiac output and systemic vascular resistance (SVR) by augmenting heart rate and contractility, which in turn will help in inducing vasoconstriction. Although dopaminergic agents can also be administered, norepinephrine will be selected since it contains beta and alpha-1 activity (beta-1 larger than beta-2), and also demonstrated slightly increased alpha-1 activity, in contrast to beta activity. This in turn would result in a more substantial increase in blood pressure, when compared to increased heart rate. Thus, administration of norepinephrine will increase blood pressure, SVR, and cardiac output (Quan & Li, 2018).

 

With the aim of restoring the heart rate to normal, the patient will be subjected to antiarrhythmic agents, which are also referred to as cardiac dysrhythmia. The patient will be administered amiodarone that belongs to the class of type II beta blockers. This medication is commonly prescribed for preventing irregular heartbeat by prolonging the phase 3 of cardiac action potential, which is commonly referred to as the repolarization phase that is characterised by an increased potassium permeability and decreased calcium permeability (Kotoda, Ishiyama, Mitsui, Hishiyama & Matsukawa, 2017). The drug will block the voltage gated calcium and potassium channels and will reduce the conduction rate, thus increasing the refractory period of the AV and SA nodes. In addition, the refractory period of the bundle of His, ventricles and Purkinje fibres will also get extended, without any major impacts of conduction rate. The patient will also be placed in a supine position in order to increase the venous return, which in turn will promote diuresis. Moreover, positioning the patient in semi-Fowler position will prove effective in lowering ventricular filling and preload, and will also lead to expansion of the chest, thus decreasing respiratory distress (Kuhajda et al., 2015). Owing to the fact that the oxygen saturation was low, the patient will be administered oxygen therapy via a cannula, thus facilitating breathing.

 

Evaluate- Effectiveness of the intervention can be assessed if the patient is able to manifest sufficient cardiac output, as observed by normalisation of pulse rate and blood pressure. The patient will be auscultated for paying attention to the internal sounds of her body. Her blood pressure shall be measured using a digital blood pressure monitor. In addition, capnography monitor will also be used for measuring the amount of carbon dioxide in each breath, thus providing an accurate estimation of the respiratory rate. Presence of strong peripheral pulse will also demonstrate the treatment has proved effective. Furthermore, the patient is also expected to demonstrate a capability of tolerating different activities, without any possible signs and symptoms of syncope, dyspnoea, and chest pain.

Reflect on process and new learning- The clinical reasoning cycle helped me to understand that in order to address hemodynamic instability, it is essential to maintain the cardiac output, besides having heart rhythm and blood pressure within normal parameters. However, I should have considered administration of inotropes that would have increased cardiac output in the patient by augmenting the contraction force of the cardiac muscles. Next time, on encountering such a patient, I would focus on inotrope administration and would also place due emphasis on the administration of phenylephrine, for treating acute hemodynamic instability. 

 

References

Bakes, K., Haukoos, J. S., Deakyne, S. J., Hopkins, E., Easter, J., McFann, K., … & Rewers, A. (2016). Effect of volume of fluid resuscitation on metabolic normalization in children presenting in diabetic ketoacidosis: A randomized controlled trial. The Journal of emergency medicine, 50(4), 551-559. https://doi.org/10.1016/j.jemermed.2015.12.003 

Collins, J. A., Rudenski, A., Gibson, J., Howard, L., & O’Driscoll, R. (2015). Relating oxygen partial pressure, saturation and content: the haemoglobin–oxygen dissociation curve. Breathe, 11(3), 194-201. DOI: 10.1183/20734735.001415

Deshmukh, N., Rath, A., Reddy, S., & Naresh, M. (2018). Gallbladder perforation in acute acalculous cholecystitis: an atypical manifestation of dengue fever. International Surgery Journal, 5(5), 1943-1945. https://dx.doi.org/10.18203/2349-2902.isj20181614

Driessen, A., Fröhlich, M., Schäfer, N., Mutschler, M., Defosse, J. M., Brockamp, T., … & Maegele, M. (2016). Prehospital volume resuscitation-Did evidence defeat the crystalloid dogma? An analysis of the TraumaRegister DGU® 2002–2012. Scandinavian journal of trauma, resuscitation and emergency medicine, 24(1), 42. https://doi.org/10.1186/s13049-016-0233-4

Giesinger, R. E., & McNamara, P. J. (2016, April). Hemodynamic instability in the critically ill neonate: an approach to cardiovascular support based on disease pathophysiology. In Seminars in perinatology (Vol. 40, No. 3, pp. 174-188). WB Saunders. https://doi.org/10.1053/j.semperi.2015.12.005 

Haase-Fielitz, A., Haase, M., Bellomo, R., Calzavacca, P., Spura, A., Baraki, H., … & Albert, C. (2017). Perioperative hemodynamic instability and fluid overload are associated with increasing acute kidney injury severity and worse outcome after cardiac surgery. Blood purification, 43(4), 298-308. https://doi.org/10.1159/000455061

Kotoda, M., Ishiyama, T., Mitsui, K., Hishiyama, S., & Matsukawa, T. (2017). Neuroprotective effects of amiodarone in a mouse model of ischemic stroke. BMC anesthesiology, 17(1), 168. https://doi.org/10.1186/s12871-017-0459-3 

Kuhajda, I., Djuric, D., Milos, K., Bijelovic, M., Milosevic, M., Ilincic, D., … & Mpakas, A. (2015). Semi-Fowler vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis. Journal of thoracic disease, 7(Suppl 1), S5. doi: 10.3978/j.issn.2072-1439.2015.01.29

Leone, A. (2015). Smoking and hypertension. J Cardiol Curr Res, 2(2), 00057. https://pdfs.semanticscholar.org/707b/3a639aae384c0540d0b62bec98be3c8abd60.pdf

Navar-Boggan, A. M., Peterson, E. D., D’Agostino Sr, R. B., Neely, B., Sniderman, A. D., & Pencina, M. J. (2015). Hyperlipidemia in early adulthood increases long-term risk of coronary heart disease. Circulation, 131(5), 451-458. https://doi.org/10.1161/CIRCULATIONAHA.114.012477 

Park, S. B., & Khattar, D. (2019). Tachypnea. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541062/

Pham, T., Shih, T., & Jucan, I. (2018). AN UNUSUAL CAUSE OF VENTRICULAR TACHYCARDIA STORM. Journal of the American College of Cardiology, 71(11 Supplement), A2538. DOI: 10.1016/S0735-1097(18)33079-1

Quan, A. T., & Li, F. (2018). Hyperinflation of Vasopressors (Vasopressin, Norepinephrine, Ephedrine, etc). Journal of pharmacy practice, 31(4), 399-402. https://doi.org/10.1177%2F0897190018770062

Shrivastava, A. K., Singh, H. V., Raizada, A., & Singh, S. K. (2015). C-reactive protein, inflammation and coronary heart disease. The Egyptian Heart Journal, 67(2), 89-97. https://doi.org/10.1016/j.ehj.2014.11.005

Tazuma, S., Unno, M., Igarashi, Y., Inui, K., Uchiyama, K., Kai, M., … & Ryozawa, S. (2017). Evidence-based clinical practice guidelines for cholelithiasis 2016. Journal of gastroenterology, 52(3), 276-300. https://doi.org/10.1007/s00535-016-1289-7 

Yaghootkar, H., Lotta, L. A., Tyrrell, J., Smit, R. A., Jones, S. E., Donnelly, L., … & Ruth, K. S. (2016). Genetic evidence for a link between favorable adiposity and lower risk of type 2 diabetes, hypertension, and heart disease. Diabetes, 65(8), 2448-2460. https://doi.org/10.2337/db15-1671

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