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)

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 Systems

RESP: 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

Hyzaar 100/12.5; Antihypertensive; angiotensin II receptor antagonists combined with a thiazide diuretic
Baby aspirin; antipyretics; nonopioid analgesics; salicylates
omeprazole; antiulcer agents; proton pump inhibitors
Pyridium; nonopioid analgesics; urinary tract analgesics

losartan 100 mg; given alone or with other agents in the management of hypertension. Treatment of diabetic nephropathy in patients with type 2 diabetes. Prevention of stroke in patients with hypertension and left ventricular hypertrophy. hydrochlorothiazide 12.5 mg; Increases excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule. Promotes excretion of chloride, potassium, hydrogen, magnesium, phosphate, calcium and bicarbonate. May produce arteriolar dilation.
Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins. Decreases platelet aggregation. Reduction of inflammation. Reduction of fever. Decreased incidence of transient ischemic attacks and MI.
Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen.
Acts locally on the urinary tract mucosa to produce analgesic or local anesthetic effects. Has no antimicrobial activity. Diminished urinary tract discomfort.

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: Midazolam 2mg IV Benadryl 12.5mg IV Zofran 4mg IV	Benzodiazepine. Enhances inhibitory effects of GABA. Produces sedation & anterograde amnesia. Antihistamine. H1 receptor antagonist. Antiemetic and produces sedation. Selective 5-HT3 receptor antagonist in GI tract & chemoreceptor trigger zone. A preventative & rescue treatment for N/V
Induction: Fentanyl Lidocaine Propofol sux	Opioid agonist. Blunts the SNS response while intubation plus provide analgesia. Binds to intracellular Na channel and stops depolarization. Blunts the SNS response & used to decrease burning feeling cause by propofol. Enhances inhibitory effects of GABA. Produces sedation. Has antiemetic & antipuretic affects. We used succinylcholine (depolarizing muscle blocker) to produce skeletal muscle paralysis after induction, this allowed us to intubate the patient. We didn’t use roc because this is an obese pt and we need something that will work fast because her FRC might decrease
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

Actual Blood Loss: 50ml

Anesthetic Implications / Problems / Concerns

Potential or Actual Problem

Proposed or Actual Intervention

Chemotherapy
Radiation
Possible movement during procedure/laser
HTN
Kidney stone

Indications for Laboratory Testing: H&H. Before surgery the CRNA need to evaluate when was the last dose of Chemotherapy given because chemotherapy cause massive cell lysis; which can cause hyperphosphatemia and hyperkalemia. Labs need to be drawn and the CRNA need to pay close attention to K and phos. Hyperphosphatemia is thought to lower plasma calcium by precipitation and deposition of calcium phosphate in bone and soft tissues. Hyperkalemia need to be assessed because succinylcholine administration can further exaggerate K level, plus elevated K can cause bradydysrhythmias
Indications for Laboratory Testing: H&H.
Patient’s eyes was protected with appropriate colored glasses and/or wet gauze. We used the lowest concentration of oxygen possible; plus, we did not using nitrous oxide (N2O), because it supports combustion. This procedure was done using a laser which requires no movement, not even coughing.
Optimize hydration status with replacement of fluid deficit. Identify potentially reversible causes of hypertension: pain, anxiety, hypothermia, bladder distention, lack of anesthesia. Maintain patient within 20% of baseline blood pressure. Poorly controlled hypertensive patient will need higher pressures to maintain adequate cerebral perfusion (autoregulation curve shifts to the right). Treatment of hypertension with adrenergic antagonists.
The kidney stone cause the patient to be in pain 10/10 on pain scale preoperatively which required her to receive pain meds by the PACU RN so she was came to us in a mild euphoric state.

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