Nursing case study
Master of Science Program in Anesthesiology
SRNA: Date: JUNE 22, 2016
Pre-op Diagnosis: LT ureteral stone
Planned Surgical Procedure: Cystoscopy: ureteroscopy, laser litherotripsy and stent placement to left side
Patient Demographics
Age: 62 | HT: 160cm | WT: 95kg | BMI: 37 |
Gender: F | NPO since: MN 9hrs | Allergies: Tramadol |
Airway Assessment
Mallampati Class: 2; soft palate, faces, portion of uvula | Neck Movement: (FULL ROM) |
Mouth Opening: >3 Finger-breadth | Dentition: 2 lower loose teeth |
Thyromental Distance: >3 Finger-breadth |
ASA Class: 2; able to see pillars and soft palate, only part of uvula METS: <4 slow walking (2mph)
R
Laboratory Findings
EKG: NSR
CXR: (—)
Other: EF 60%
Hgb 12 Ptt 26
Hct 37 Pt 13
WBC 7 INR 1.1
Platelet 225 BUN 20
K 4.6 Creatinine 1.1
Na 142 Glucose 105
eview of SystemsRESP: B/L breath sounds clear on auscultation
CV: SR on cardiac monitor, no mummers heard. S1/ S2
CNS: AAOX4
HEP/RENAL: Kindey stone
ENDOCRINE: (—)
GI: (—)
OTHER: Rt breast cancer
HISTORY:
Medical/Surgical: Rt breast Lumpectomy
Anesthetic: GETA
Social: patient denies
Family: No family history with problems with anesthesia
Medications / Dosage / Classification | Anesthetic Implications |
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Anesthetic Implications
Surgical Procedure Description: The surgeon passes a small lighted tube (ureteroscope), through the urethra and bladder and into the ureter to the point where the stone is located. If the stone is small, it may be snared with a basket device and removed whole from the ureter. If the stone is large and/or if the diameter of the ureter is narrow, the stone will need to be fragmented, which is usually accomplished with a laser. Once the stone is broken into tiny pieces, these pieces are usually removed from the ureter. In most cases, to ensure that the kidney drains urine well after surgery, a ureteral stent is left in place. Ureteroscopy can also be performed for stones located within the kidney. Similar to ureteral stones, kidney stones can be fragmented and removed with baskets. Occasionally, a kidney stone will fragment with a laser into very small pieces (grains of sand), too small to be basketed. The urologist will usually leave a stent and allow these pieces to clear by themselves over time. Lastly, if the ureter is too small to advance the ureteroscope, the urologist will usually leave a stent, allowing the ureter to “dilate” around the stent, and reschedule the procedure for 2-3 weeks later. Ureteroscopy is usually performed as an outpatient procedure. Some patients, however, may require an overnight hospital stay if the procedure proves lengthy or difficult.
Anesthetic Plan
Rationale | |
1. Technique: General ETT with muscle relaxer | This procedure is done using a laser which requires no movement, If the patient cough the unexpected movement could cause dire consequences. |
2. Alternative Plan: Spinal, blocking up to T9-T10 | This procedure can be done with spinal anesthesia but its not preferred because the medication could wear off before the surgery and case the patient to move. |
Monitoring and Special Equipment: Spontaneous ventilation, Negative inspiratory force > 20 cmH2O, Vital capacity > 15 ml/kg, Regular respiratory pattern, Paralytics reversed, Equal grip strength, head lift > 5 sec, Awake and responsive with stable VS | Meeting extubation criteria provides protection of airway, prevention of obstruction/bronchospasm/laryngospasm. |
Surgical Positioning: Lithotomy | Anesthetic Implications: Patient is supine with arms extended laterally <90 degrees. Each lower extremity is flexed at the hip (about 90 degrees) and knees bent parallel to the floor. Extremities should be elevated and lowered slowly and together. Seen most often in GYN and Urology cases. Hip flexion >90 degrees can increase stretch of the inguinal ligaments. Complications: Can impair ventilation due to upward pressure; more prominent in obese pt’s. Nerve injuries! Most common problem with lithotomy Injuries: Sciatic, common peroneal, femoral, saphenous and obturator. Common peroneal nerve damage occurs from compression of lateral aspect of fibula head (improper padding against stirrups) Avoids stretching of one side of the nerve > 4 hrs in lithotomy increases risk of injury. Ischemia, edema to skin and muscles. |
Pharmacologic Intervention
Rationale | |
Pre-Operative Medication:
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& rescue treatment for N/V |
Induction:
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Maintenance and Other Pharmacologic Intervention: Sevo | Volatile anesthetic used for maintenance of anesthesia. It can cause Compound A which leads to renal failure, to stop this from happening before removing the tube we ran 2L/min to minimize production of Compound A. |
Emergence: Regular spontaneous respiratory pattern, Paralytics reversed, Equal grip strength, head lift > 5 sec, Awake and responsive with stable VS, TV >4ml/kg | Meeting extubation criteria provides protection of airway, prevention of obstructions such as laryngospasm. |
Fluid Management
FLUIDS | 1ST HOUR | 2ND HOUR | 3RD HOUR |
Deficit: 1080 mL | 540mL | 270mL | 270mL |
Maintenance: 135mL/hr | 135mL | 135mL | 135mL |
3RD Space: 3mL/hr | 285mL | 285mL | 285mL |
TOTAL | 960ml | 690ml | 690ml |
EBV: 6175 65ml/kg X 95kg | ABL: 6175 (37-30) ————————————— = 1,168ml 37 Actual Blood Loss: 50ml |
Anesthetic Implications / Problems / Concerns
Potential or Actual Problem | Proposed or Actual Intervention |
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