Introduction
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