A case study by Arwinder Singh of a patient who underwent bilateral retrograde change of urethral stents following stent placement due to prostate cancer.
A case study is an important aspect of development in clinical practice and allows the individual the opportunity to reflect on clinical processes and determine specific learning needs in response to these processes (Gerring, 2004). Furthermore, a case study can help in outlining the need for holistic care of patients which focuses on biological, social and psychological components of routine care (Selimen and Andsoy, 2011). Best practice guidelines indicate that patient confidentiality must be respected at all times and therefore patient identifiers are removed from the case study and such information is made anonymous, hence the name of the patient in the below has been changed [UK government, 1998, Data Protection Act; Health and Care Professions Council (HCPC) 2012; Nursing and Midwifery Council (NMC) 2015].
Mr Davies is a 70-year-old patient weighing 80kg who underwent bilateral retrograde change of urethral stents following stent placement due to prostate cancer. He had been informed on the morning of the operation about the procedure to be carried out, risks and possible complications. Furthermore, his legal rights and ethical issues concerning anaesthetic procedure were outlined. He then signed, together with the surgeon in charge, a consent form in which he additionally stated acceptance to use this surgical procedure as a case study.
Pre-operative Anaesthetic Assessment
On the morning of surgery, the patient was prepared for theatre and examined by the anaesthetist. A detailed medical and surgical history was taken which revealed him to be a persistent smoker, smoking 25 cigarettes per day for the last 40 years, with a past medical history significant for chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2 (DM2), chronic vascular disease, hypertension, hypercholesterolaemia and deep vein thrombosis (DVT). His surgical history included an aortobifemoral bypass 4–6 years ago, which reflected the longstanding vascular disease suffered by the patient (Abelha, et al, 2010). At the time of surgery, his medication use included steroids, seretide, ventolin and tiotropium for COPD management. He was also taking medication for his chronic diseases and had no known allergies.
Airway control is important as 85 per cent of inaccuracy can result in permanent cerebral damage (Caplan et al., 1990). A Mallampati test is an assessment of the airway which provides a view of the patient’s mouth as (a) good visualisation of the soft palate, fauces, uvula, and tonsillar pillars; (b) pillars obscured by the base of the tongue but the soft palate, fauces, and uvula visible; (c) soft palate and base of the uvula visible; and (d) soft palate not visible (Samsoon and Young, 1987).
A classification based on preoperative patient physical status for anaesthetic risk assessment was proposed by the American Society of Anaesthesiologists (ASA). The ASA score, for assessment of patient’s health is based on five classes (Daabiss, 2011):
1. Patient is completely healthy fit patient.
2. Patient has mild systemic disease.
3. Patient has severe systemic disease that is not incapacitating.
4. Patient has incapacitating disease that is a constant threat to life.
5. A moribund patient who is not expected to live 24 hour with or without surgery.
Mr Davies was graded ASA 3, indicating he had a severe systemic disease and must receive special care during surgery. It has been reported that ASA 3 is correlated with greater blood loss (Grosflam et al., 1995) and therefore transfusion units must be available. Smoking causes concern when planning perioperative care. It reduces the ability of blood to carry oxygen and induces an inflammatory state in the lungs with alteration in inflammatory cells’ function (Canet and Briones, 2007).
Anaesthetic machine check
Anaesthetic machines dispense a mixture of gases in varying proportions to control the patient’s level of consciousness and analgesia during surgical procedures. The machine performs four functions: it provides oxygen, mixes anaesthetic gases and vapours accurately, enables patient ventilation and minimises risks to patients and staff. Piped oxygen is drawn from the central oxygen source, which may be a vacuum evaporator, a cylinder or an oxygen concentrator. Piped medical air may be supplied from either a cylinder manifold or a compressor with an outlet filter (Hartle et al., 2012). Nitrous oxide is supplied from a cylinder manifold.
Gases are fed into a labelled and colour-coded pipeline distribution network, which terminates in self-closing sockets at the wall. Flexible pipelines connect the terminal outlet to the anaesthetic machine. Reducing valves ensure the pipeline pressure of anaesthetic gas services is 4 bar. Flexible pipelines have three components: Schrader probe, flexible hosepipe, non-interchangeable screw thread (NIST) connection to the anaesthetic machine (Australian and New Zealand College of Anaesthetists (ANZCA), 2012).
Cylinders usually serve as a reserve, should a central gas supply fail. They are mounted on yokes attached to the machine. A valve block screws into the open end of the cylinder; the valve opens on turning a longitudinal spindle, and leaks are prevented by the compression of a nylon ring called a bodok seal around the spindle. A safety outlet is fitted between the valve block and the cylinder neck (ANZCA, 2012). The pressure in a full oxygen or air cylinder at 20°C is 137 bar. The pressures in full nitrous oxide and carbon dioxide cylinders are approximately 52 and 58 bar, respectively. Each gas entering the machine from a cylinder flows through a filter, one-way check valve and primary regulator. Gauges are fitted adjacent to each yoke and pipeline connection. These are calibrated, labelled and colour-coded for each gas service (Hartle et al., 2012).
Modern machines have several primary and secondary regulators. Primary regulators reduce potentially dangerous high cylinder pressures to the machine working pressure of 4 bar (420 kPa). Some regulators weep their cylinder contents, hence the importance of turning a cylinder off after a machine check. Secondary regulators level out gas delivery (Stuart-Andrew et al., 2007). Machine working pressures may vary by up to 20 per cent, for example during periods of peak hospital demand. Secondary regulators set below the anticipated decrease in pressure will make the emergent pressure more uniform.
The anaesthetic machine was checked prior to use in the induction process. This is a mandatory check involving the assessment of all functions of the machine that is essential to patient safety and has been included in the World Health Organization Surgical Safety Check List (NPSA, 2009). For the purposes of this case study, however, three areas will be expanded upon: the circle breathing system, the suction and the hypoxic guard functions (Association of Anaesthetists of Great Britain and Ireland (AAGBI), 2012).
The anaesthetic machine has a circle breathing system attached, a rebreathing system commonly used in anaesthetic practice consisting of a circuit whereby gas flows through a one- way inspiratory valve to the patient’s lungs and then through the expiratory valve where gas is removed and carbon dioxide is absorbed. This allows the gas to flow back to the patient in a circular loop (Squara et al., 2007). The suction device is essential in anaesthetic practice in order to scavenge waste gases and remove excess secretions from the mouth and airways that can impair delivery of anaesthetic agents (Hedenstierna and Edmark, 2005). The hypoxic guard prevents the overuse of nitrous oxide (100 per cent) by connecting the control of nitrous oxide with that of oxygenation in order to reduce hypoxic situations (Bruce et al, 2001). A ratio of 1:3 for oxygen: nitrous oxide is often maintained as a minimum in these systems (Yu, et al., 2006).
In light of Mr Davies’ medical history and current status, there were a number of considerations to be made regarding the delivery of anaesthesia. First, the underlying COPD in this patient was likely to require special consideration (Licker et al., 2007). Bronchodilator therapy should be optimised prior to surgery and smoking cessation encouraged in order to improve outcomes (Barrera et al., 2005). Patients with COPD may be more susceptible to the ventilatory depressant effects of anaesthetic agents and where possible regional and general combined anaesthesia should be used in preference to general anaesthesia alone (Bonnet and Marret, 2005). Administration of hydrocortisone prior to anaesthesia may be required to prevent difficulty in blood pressure control and should be continued in the post-operative period (Davies and Hardman, 2005).
Mr Davies’ COPD would have consequences on the functional residual capacity which would be decreased and this may increase the potential for him to become septic (Lanone et al., 2005). Furthermore, once induction commenced it would be more likely that hypotension would occur in the case of pronounced sepsis (Lanone et al., 2005). As a result, the anaesthetist utilised an intravenous induction but in a cardio-stable manner, utilising opioids and very little inducing agent (Warner, 2002). For the induction process an intravenous dose of fentanyl (1mcg/kg) can be used, but in this case more fentanyl was used, as it has a better cardio-stability profile than propofol (Grocott et al., 2005).
Preparation of equipment
The airway trolley and equipment were prepared and checked. Controlled drugs form an essential part of the anaesthetist’s preparation and the operating department practitioner (ODP) was asked to retrieve these drugs from the controlled drugs cabinet, consistent with guidelines (AAGBI, 2006). Drugs drawn up included fentanyl, propofol and atracurium, along with several emergency drugs.
These drugs are described in more detail in Table 1.
Table 1. Anaesthetic Emergency Drugs
|Metaraminol||Management of hypotension||15-100mg in 500 ml I.V. infusion|
|Ephedrine||Management of hypotension||3-6mg bolus as required solution strength: 3mg/ml|
|Atropine||Decreases bronchial secretions, increases heart rate||20 mg/kg IM or up to 500 mg I.V. before induction of anaesthesia.|
|Suxamethonium||Muscle relaxant||1-2 mg/kg I.V.
3 mg/kg I.M.
|Noradrenaline||Vasoconstriction, blood pressure control||0.125mcg/kg body weight|
|Adrenaline||Vasoconstriction||50 mg (0.5ml) of 1:10 000 solution I.V.|
Check in Patient
As well as ensuring medical and biological safety of the patient during anaesthesia it is important that other needs are addressed including clarity in communication and consent for the procedure (HCPC, 2012). The WHO checklist (World Health Organization (WHO), 2008) was completed, along with the checking of the consent form, with Mr Davies receiving information on the purpose of the procedure and the potential risks (Conway et al., 2009). Patient choice is essential in medicine and this was adhered to in this case study by providing optimal information in a sensitive and understanding manner (HCPC, 2012).
The Anaesthetic Process
Mr Davies was informed that monitoring devices were to be attached in order to ensure there were no problems during the procedure and that these could be rectified swiftly if they arose (Bruce et al., 2001). These devices included the electrocardiogram (ECG), end tidal carbon dioxide monitor, oxygen saturation probe and non-invasive blood pressure monitoring. Mr Davies had a blood pressure level slightly higher than one might normally expect (137/79 mmHg), with an average of 120/80 mmHg often cited in the literature (Bruce et al., 2001);however, in the light of longstanding hypertension, this is a good blood pressure reading.
Monitoring ECG in the perioperative period conveys useful information to the anaesthetist. It is a useful monitor as the condition of a patient under anaesthesia is optimally reflected by biological electric signals (Schamroth, 1993). The lead system generates an electric field where the heart is situated in the centre (Dash, 2002). Monitoring may be carried out using a three-electrode system, whereby electrodes are placed on the right arm (RA), left arm (LA) and left leg (LL). In the modified chest leads system, the same three electrodes are used but there is a change in position on the body to correspond with CS5 (right clavicle), CM5 (manubrium), CB5 (right scapula) and CC5 (right anterior axillary line) (Griffin and Kapan, 1987).
A pulse oximeter was placed on Mr Davies’ index finger of his right hand. It measures blood oxygen saturation (SpO2) level, which should normally be around 94 to 99 per cent. For patients with mild respiratory diseases, the SpO2 should be 90 per cent or above. Supplementary oxygen should be used if SpO2 level falls below 90 per cent (Soh, Tawng and Mahadev, 2013).
Blood pressure (BP) is the force which circulates the blood around the body (Cheesbrough, 1991). It is measured by using a non-invasive blood pressure monitoring (NIBP) system. A BP cuff was applied to Mr Davies non-dominant arm (left) and normally to the opposite side to where the IV cannula and saturation probe are placed. The blood pressure reading provides useful information with reference to tissue perfusion, cardiac output and stroke volume.
Table 2. Values of Vitality Signs of the Patient compared with the Normal Range
|Parameter||Mr Davies||Normal Range||Reason for Deviation from Normal|
|Blood Pressure||137/79 mmHg||Average 120/80 mmHg||Patient has long-standing hypertension|
|Pulse Rate||115 bpm||60-100 bpm||Reflects increased heart rate|
|Respiratory Rate||19/min||12-15 times/min||Due to circulatory and respiratory problems|
|Oxygen Saturation||96% on air||94% – 99%||Normal|
A 16G cannula was requested by the anaesthetist to enable larger volumes of fluid to be delivered, particularly in light of Mr Davies’ risk of hypertension (Rizoli, 2011). A tourniquet was applied to prevent venous return and the cannula was inserted on the dorsum of the left hand and then the fluid was attached. Plasmalyte fluid was prepared in order to compensate for relative fluid loss in the vascular compartment due to vasodilatation and thus reduce the effects of hypotension (Rizoli, 2011). Plasmalyte is a crystalloid solution that closely resembles human plasma and is thus one of the most effective fluids that can be delivered in this context, maintaining intravascular volume and correcting electrolyte imbalance/acidosis (Rizoli, 2011).
Induction was preceded by 3 minutes of pre-oxygenation in order to maximise the time Mr Davies could experience apnoea often experienced during the induction process (Pino, 2006). Following this stage, 100mcg fentanyl and 30mg propofol were used for induction, a combination of opioid and hypnotic, justified in light of the need to minimise the hypotension and cardiovascular instability potentially associated with higher doses of propofol (Buhre and Rossaint, 2003). Atracurium (40mg) was used as a muscle relaxant, which took 90–120 seconds to work, after which respiration ceased, following by administration of the anaesthetic agent isoflurane (Hendenstierna and Edmark, 2005). The dose of all drugs were based on a body weight of 80kg; this is standard procedure, as body weight reflects tissue effects of agents more accurately than other measures such as body mass index (Buhre and Rossaint, 2003).
The anaesthetist decided that a size 9.00mm (internal diameter) endotracheal tube would be used and it was prepared accordingly. The intubation process required passing a laryngoscope with a Macintosh size 3 blade in order that the tongue could be depressed and the airway opened. While the endotracheal tube was passed down the throat, approximately 10ml of air was used to inflate the pilot ballon to correct for excessive cuff pressure and prevent aspiration into the lungs (Galinski et al., 2006). Misting in the tube, bilateral chest movements and capnograph end-tidal carbon dioxide readings, which is defined as the minimal cuff pressure required to avoid a carbon dioxide pressure leak of >2mmHg proximal to the tube cuff, were consistent with a successfully placed tube, with no signs of obstruction (Peterson et al., 2005).
Metaraminol was administered, acting as an alpha-agonist in order to raise Mr Davies’ blood pressure (Buhre and Rossaint, 2003). This was done using an aseptic technique through the central venous catheter to deliver the medication into the subclavian vein, where it can be rapidly distributed while venous pressure monitoring can also be conducted (Buhre and Rossaint, 2003). Ten boluses of 0.5 were administered in total, emphasising the advantage of utilising the catheter for large doses of medication over periods of time (Pino, 2006).
Maintenance of anaesthesia
Mr Davies was transferred to the operating table according to manual handling regulations (Manual Handling Operations Regulations (MHOR), 1992) in a supine position. The saturation probe was the first monitoring device attached in theatre in order to ensure hypoxia had not occurred. Mr Davies was also noted to have a temperature of 36.2°C and a warming device was attached in order to maintain core temperature and prevent hypothermia which can be detrimental during surgery (Peterson et al., 2005).
The patient was ventilated using intermittent positive pressure ventilation (IPPV) techniques of respiration using isoflurane, nitrous oxide and constant oxygen, with an end-tidal mean alveolar concentration of 1.1. The minimum alveolar concentration (MAC) of an inhaled anaesthetic is the alveolar concentration at which 50 per cent of patients will not show a motor response to a standardised surgical incision. It is used to compare potency of different anaesthetics and its values are additive in terms of preventing movement to incision (Chohan et al., 2013). Biochemical testing during the procedure revealed a haemoglobin value of 6.6, an elevated white cell count of 25, potassium of 3.2, hypomagnesaemia and a creatinine level of 255. The low haemoglobin indicates anaemia, which may be the result of chronic disease or blood loss, either acutely or in the chronic setting (Licker et al., 2007). Anaemia impairs the ability of blood to transport oxygen effectively and may result in exacerbation of respiratory symptoms. The elevated white cell count was probably due to the sepsis diagnosed prior to surgery and, provided this is a part of a downward trend, it was considered that it should not be problematic in this scenario (Radford, 2002).
The metabolic changes may have been of greater significance in this case, with low potassium increasing the irritability of the cardiac tissue, increasing the risk of arrhythmias, and hypomagnesaemia also contributing to an increased risk of hypertension and arrhythmia (Licker et al., 2007). Creatinine is a broad marker of renal function and elevated levels tend to indicate reduced renal clearance, potentially indicating dehydration or more severe disease. Arterial blood gas noted a pH of 7.197, indicating acidosis, which could be due to increased carbon dioxide retention in light of the patient’s COPD (Licker et al., 2007).
In order to manage changes in blood pressure during anaesthesia, plasmalyte (4 litres total) was administered and noradrenaline was infused at a rate of 0.125mcg/kg per min (Warner, 2002). Noradrenaline is a pure alpha-agonist and helps to maintain blood pressure in light of the fact that both sepsis and anaesthetic agents increase peripheral vasodilation, reducing blood pressure (Warner, 2002).
Prevention of infection during urological procedures is also of paramount importance, particularly as instrumentation in this process is associated with a high risk of infection, and gentamicin (240mg) and teicoplanin (400mg) were administered. Gentamicin is especially useful in this context as the drug does not undergo nephrological metabolism and thus targets the kidneys and associated tissue specifically (Bootsma et al., 2008).
Finally, towards the end of the procedure the anaesthetist initiated the process of spontaneous breathing. Mr Davies was able to follow commands and met the criteria for extubation, but oxygen saturation levels were only 94 per cent with the fraction of inspired oxygen of 70 per cent and required a positive end-
expiratory pressure (PEEP) of 9cm H20 in order to maintain alveolar patency (Squara et al., 2007). He was admitted to the intensive therapy unit (ITU) where he required further medical input and was extubated the following day.
Mr Davies received a high standard of care through the perioperative phase. The indication of anaesthesia and surgical procedures were explained with proper response to his questions. The patient had a complex series of acute and chronic conditions affecting blood pressure and cardiovascular stability; hence a pre-operative plan was formulated sufficiently to address these problems. The holistic care that was delivered – not only from a biological, but also a psychological perspective – yielded an optimal outcome in this instance. All involved staff treated Mr Davies in a careful dignified manner and kept him safe at all times.
Abelha, F.J., Botelho, M., Fernandes, V. and Barros, H., 2010. Outcome and quality of life after aorto-bifemoral bypass. BMC Cardiovascular Disorders, 10(15).
Association of Anaesthetists of Great Britain and Ireland (AAGBI), 2006. Controlled drugs. [pdf] London: AAGBI. Available at: http://www.aagbi.org/sites/default/files/controlleddrugs06_0.pdf [Accessed 25 August 2015].
Association of Anaesthetists of Great Britain and Ireland (AAGBI), 2012. Checking Anaesthetic Equipment. [pdf] London: AAGBI. Available at: http://www.aagbi.org/sites/default/files/checking_anaesthetic_equipment_2012.pdf [Accessed 25 August 2015].
Australian and New Zealand College of Anaesthetists (ANZCA), 2012. Recommendations on Checking Anaesthesia Delivery Systems. [pdf] Melbourne: ANZCA. Available at: http://www.anzca.edu.au/resources/professional-documents/pdfs/ps31-2014-guidelines-on-checking-anaesthesia-delivery-systems.pdf [Accessed 25 August 2015].
Barrera, R., Shi, W., Amar, D., et al., 2005. Smoking and timing of cessation: impact on pulmonary complications after thoracotomy. Chest, 127(6), pp.1977-1983.
Bonnet, F. and Marret, E., 2005. Influence of anaesthetic and analgesic techniques on outcome after surgery. British Journal of Anaesthesia, 95(1), pp.52-58.
Bootsma, A.M., Laguna Pes, M.P., Geerlings, S.E. and Goossens, A., 2008. Antibiotic prophylaxis in urological procedures: a systematic review. European Urology, 54(6), pp.1270-1286.
Bruce, J., Russell E.M., Mollison, J. and Krukowski, Z.H., 2001. The measurement and monitoring of surgical adverse events. Health Technology Assessment, 5(22), pp.1-194.
Buhre, W. and Rossaint, R., 2003. Perioperative management and monitoring in anaesthesia. Lancet, 362(9398), pp.1839-1846.
Canet, J. and Briones, Z., 2007. Anaesthesia in smokers. European Society of Anaesthesiology meeting. Munich, Germany, 9-12 June 2007.
Caplan, R.A., Posner, K.L., Ward, R.J and Cheney, F.W., 1990. Adverse respiratory events in anesthesia: A closed claims analysis. Anesthesiology, 72(5), pp.828-833.
Cheesbrough, M., 1991. Medical Laboratory Manual for Tropical Countries. 2nd Edition (Reprinted). Oxford: ELBS Butterworth-Heinemann.
Chohan, A.S., Greene, S.A., Keegan, R.D., Grubb, T.L. and Chen, A.V., 2013. Intracranial pressure and cardiopulmonary variables during isoflurane or sevoflurane anaesthesia at minimum alveolar concentration multiples in normocapnic dogs. American Journal of Veterinary Research, 74(3), pp.369-374.
Conway, N., Ong, P., Bowers, M. and Grimmett, N., 2009. Clinical Pocket Reference: Operating department Practice. Oxford: Pennant Health Publishing.
Daabiss, M., 2011. American Society of Anaesthesiologists Physical status classification. Indian Journal of Anaesthetics, 55(2), pp.111-115.
Dash, P.K., 2002. Electrocardiogram Monitoring. Indian Journal of Anaesthetics, 46(4), pp.251-260.
Davies, M. and Hardman, J., 2005. Anaesthesia and adrenocortical disease. Continuing Education in Anaesthesia. Critical Care and Pain, 5(4), pp.122-126.
Galinski, M., Treoux, V., Garrigue, B., et al., 2006. Intracuff pressures of endotracheal tubes in the management of airway emergencies: the need for pressure monitoring. Annals of Emergency Medicine, 47(6), pp.545-547. Gerring, J., 2004. What is a case study and what is it good for?American Political Science Review, 98(2), pp.341-354.
Griffin, R.M. and Kapan, J.A., 1987. Myocardial ischaemia during non-cardiac surgery. A comparison of different lead systems using computerised ST segment analysis. Anaesthesia, (42)2, pp.155-159.
Grocott, M.P., Mythen, M.G. and Gan, T.J., 2005. Perioperative fluid management and clinical outcomes in adults. Anaesthesia and Analgesia, 100(4), pp.1093-1106.
Grosflam, J.M., Wright, E., Cleary, P. and Katz, J.N.,1995. Predictors of blood loss during total hip replacement surgery. Arthritis Care and Research, 8(3), pp.167-173.
Hartle, A., Anderson, E., Bythell, V., et al., 2012 Checking anaesthetic equipment. Association of Anaesthetists of Great Britain and Ireland. Anaesthesia, 67(6), pp.660-668.
Health and Care Professions Council (HCPC), 2012. Information for students and education providers. [pdf] London: HCPC. Available at: http://www.hpc-uk.org/assets/documents/10002D1BGuid anceonconductandethicsforstudents.pdf [Accessed 25 August 2015].
Hedenstierna, G. and Edmark, L., 2005. The effects of anaesthesia and muscle paralysis on the respiratory system. Intensive Care Medicine, 31(10), pp.1327-1335.
Lanone, S., Taille, C., Boczkowski, J. and Aubier, M., 2005. Diaphragmatic fatigue during sepsis and septic shock. Intensive Care Medicine, 31(12), pp.1611-1617.
Licker, M., Schweiser, A., Ellenberger, C., et al., 2007. Perioperative management of patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease, 2(4), pp.493-515.
National Patient Safety Agency (NPSA), 2009. WHO Surgical Safety Checklist. [online] London: NPSA. Available at: http://www.nrls.npsa.nhs.uk/resources/ [Accessed 25 August 2015].
Nursing and Midwifery Council (NMC), 2015. Standards of conduct, performance and Ethics. [online] London: NMC. Available at: http://www.nmc.org.uk/news/news-and-updates/new-code- comes-into-force-for-every-nurse-and-midwife [Accessed 20th August 2015].
Peterson, G.N., Domino, K.B., Caplan, R.A., et al., 2005. Management of the difficult airway: a closed claims analysis. Anesthesiology, 103(1), pp.33-39.
Pino, R.M., 2006. Residual neuromuscular blockade: a persistent clinical problem. International Anesthesiology Clinics , 44(2), pp.77-90.
Radford, H.M., 2002. Sepsis, severe sepsis and septic shock in adults and anaesthesia. Southern African Journal of Anaesthesia and Analgesia, 8(2), pp.30-42.
Rizoli, S., 2011. PlasmaLyte. The Journal of Trauma, 70(5), S17-S18. Samsoon, G.L. and Young, J.R., 1987. Difficult tracheal intubation: A retrospective study. Anaesthesia, 42(5), pp.487-490.
Schamroth, L., 1993. Basic Principles: An Introduction to Electrocardiography. Oxford University Press.
Selimen, D. and Andsoy, I.I., 2011. The importance of a holistic approach during the perioperative period. AORN Journal, 93(4), pp.482-487.
Soh, R.C., Tawng, D.K. and Mahadev, A., 2013. Pulse oximetry for the diagnosis and prediction for surgical exploration in the pulseless perfused hand as a result of supracondylar fractures of the distal humerus. Clinics in orthopedic surgery, 5(1), pp.74-81.
Squara, P., Denjean, D., Estagnasie, P., et al., 2007. Noninvasive cardiac output monitoring (NICOM): a clinical validation. Intensive Care Medicine, 33(7), pp.1191-1194.
Stuart-Andrews, C., Peyton, P., Robinson, G., et al., 2007. Non- invasive metabolic monitoring of patients under anaesthesia by continuous indirect calorimetry – an in vivo trial of a new method. British Journal of Anaesthesia, 98(1), pp.45-52.
UK government, 1992. The Manual Handling Operations Regulations 1992. [online] London: Health and Safety Executive. Available at: http://www.hse.gov.uk/msd/faq-manhand.htm [Accessed 25 August 2015].
UK government, 1998. Data Protection Act 1998. [online] London: The National Archives. Available at: http://www.legislation.gov.uk/ukpga/1998/29/contents [Accessed 25 August 2015].
Warner, D.O., 2002. Diaphragm function during anesthesia: still crazy after all these years. Anesthesiology, 97(2), pp.295-297.
World Health Organization (WHO), 2008. WHO surgical safety checklist and implementation manual. [online] Geneva: WHO. Available at: http://www.who.int/patientsafety/safesurgery/ss checklist/en/ [Accessed 25 August 2015].
Yu, G., Yang, K., Baker, A.B. and Young, I., 2006. The effect of bi-level positive airway pressure mechanical ventilation on gas exchange during general anaesthesia. British Journal of Anaesthesia, 96(4), pp.522-532.
Arwinder Singh qualified in 2014 as an operating department practitioner. He returned to full-time education to complete his undergraduate degree and graduated with a first-class honours degree in Acute Care in 2015.