Case Study Majri

CASE STUDY ON THE USE OF
COMBINED GENERAL ANAESTHESIA

WITH EPIDURAL FOR PATIENT UNDER
GONE TOTAL ABDOMINAL
HYSTERECTOMY BILATERAL
SALPIGO-OOPHORECTOMY
PPP MAJRI BIN ABAS

PAC 2/2008
December 8, 2021 GA+EPIDURAL - TAHBSO
Introductions
 Anaesthesia involves the administration of
potentially lethal drugs and gases. Care of
patient for pre, intra and post operatively
play important role, also to provide a
maximum safety and comfort for the
patient.
December 8, 2021 GA+EPIDURAL

GA+EPIDURAL -- TAHBSO
TAHBSO
General objective
 By doing this case study on the use of
combined general anaesthesia with
epidural for patient under gone total
abdominal hysterectomy bilateral Salpigo-
oophorectomy is to ensure that all
preparations for patient undergone surgery
will be successful and reduce pre, intra
and postoperative complications

TAHBSO
Specific Objective
 To participate in technique using in
giving anaesthesia, rapid sequence
induction.
 To improved skilled when performing
cricoids pressure and the important of
cricoids pressure.
 To provide care of patient for pre, intra
and post using nursing process.

TAHBSO
Anatomy and physiology of the
system involved.
Respiratory System

TAHBSO
Anatomy Epidural Space

TAHBSO
Anatomy of female
reproductive system

TAHBSO
Patient Particular
Name : Mrs S
IC NO. : 590218105044
RN. : 1171118
Age : 49 years old
Sex : Female
Race : Malay
TAHBSO
Present History
 Had abdominal swelling since June

2007
 Only sought 7 times
 On April 2008 diagnosed as ovarian
carcinoma

TAHBSO
Past Medical And Surgical
History
 No known medical illness

 No history of chest pain/orthopnea
 No known allergy of drug and food
 Known case of migraine especially
pre menstrual last attack 2003, now
much better
TAHBSO
 No surgical history
 Obstetric history – Para 3, full term
spontaneous virginal delivery

TAHBSO
Treatments
 Tablet Propanolol 40 mg. BD for migraine
prophylaxis

TAHBSO
Investigations
 Full Blood Count

 BUSE
 RBS
 ECG
 Chest X-Ray

TAHBSO
Type Of Operation Planned
 Combined general anaesthesia with
epidural

TAHBSO
Definition of General
anaesthesia
 General anaesthesia is a treatment that puts
you to sleep during medical procedures, so you
do not feel or remember anything that happens.
General anaesthesia is commonly produced by
intravenous drugs or inhaled gasses.
 The "sleep" you experience under general
anaesthesia is different from regular sleep. The
anesthetized brain does not form memories or
respond to pain signals.

TAHBSO
 General Anaesthesia is the most common type of
anaesthesia for surgery. You will be in a sleep state
during the surgery. You will have no pain. You will
remember little about the surgery or recovery period.
There are several methods of giving general
anaesthesia. Many aesthetic drugs are now available,
and they help make your anaesthesia safer than ever
before. The selection of which drugs are used depends
on your physical condition and the type of surgery you
are having. Injecting medicines into a vein, or having you
breathe a gas from the anaesthesia machine administers
usually general anaesthesia.

TAHBSO
Definition of Regional
Anaesthesia
 Regional Anaesthesia is used to numb only
a specific part of the body. A local
aesthetic (numbing medicine) is injected
into the area, where it blocks pain
sensations. There are many types of
regional anaesthesia. The most common
are: spinal, epidural, and Bier blocks.

TAHBSO
 Epidural anaesthesia is a neuraxial
technique offering wide range of
applications for procedures below the neck
level. An epidural block can be performed
at cervical, thoracic, or lumbar levels.
Since autonomic, sensory and motor block
occur with an epidural, it can be used for
surgical anaesthesia where relaxation is
required.
TAHBSO
Indication of General
anaesthesia
 For airway protection since case
need to be done under general
anaesthesia
 Case cannot be done spinal
because this is a major operation.
 Patient treats as full stomach
condition because she had mass
in abdomen cavity.
 Long time operation 4 hours.
TAHBSO
Indication of Epidural
 postoperative pain control

Preparations
 Preparation of equipment (MALES)
 GA machine - checked for leaking
 Airway – oropharyngeal airway – 3 sizes –
size 3, 4 and 5.
 Proper size facemask – tight seal cover mouth
and nose.
 Laryngoscope with curved blade (Macintosh)
in which the bulbs works.
 Lubricant – with lignocaine gel

 Endotrachel various sizes – prepare in 3 sizes
– 7.5mm, 8.0mm and 8.5mm.
 Stylet as guide for endotracheal tube
 Syringe 20ml to inflate the cuff once the tube
is in place.
 Stethoscope to check correct placement of
the tube by listening for breath sound.
 Suction machine function, to remove
secretions.
 Plaster/string to anchor endotracheal tube at
the level of the patient teeth.

Preparation for Intubation
G.A. Machine
Breathing
December 8, 2021 Circuit and CO2 -Absorber
GA+EPIDURAL TAHBSO
 Preparation of drugs.
 Induction agent.
 Injection Propofol 50 mg
 Injection Fentanyl100 mg
 Muscle relaxant.
 Injection Sux (scoline)
 Injection Esmeron 60 mg

 Reversal.
 Injection Atropine 1 mg
 Injection Neostigmine 2.5 mg
 NSAID
 Injection Parecoxib 40 mg (Dynastat)
 Injection Dexamethasone 4 mg
 Antibiotic
 Injection Cefuroxime 1.5 gm

December 8, 2021
Preparation of Drugs
GA+EPIDURAL - TAHBSO
Preparation
December 8, 2021
of Epidural
GA+EPIDURAL - TAHBSO
 Preparation of patients
 Inform about the consent
 consent for operation
 Consent for anaesthesia
 Consent for blood
 Nil by mouth – to empty the stomach for 6 to
8 hours to prevent complication during
intubations.
 Give emotional support by listening patient
express regarding operation. Answer all
questions or any doubt so that patient
understands and less worried.

 Position of the patient – sniffing position /
morning sniff position serve to align the
oral, pharyngeal and laryngeal axis, so
that the passage from the lip to the glottic
opening is almost a straight line. This
position permits better visualization of the
glottis and vocal cord and allows easier
passage of the endotracheal tube.
 Ensure good intravenous line and patent.
 Vital sign taken as baseline data.

 Attached all monitor such as SPO2 probe
 make sure proper position of SPO2 infrared
and photodetacted are parallel for better
reading.
 Blood Pressure cuff - proper size 2/3-
circumference upper arm. ECG electrodes
attached.
 Put patient on warming device or warm
blanket to prevent hypothermia.

Sitting Position for Epidural

 The legs are allowed to hang over the
edge of the bed with the feet supported by
a stool.
 The shoulders are “hunched” forward and
the patient is encouraged to hug a pillow in
towards the abdomen to provide anterior
flexion of the spine.
 This position helps to identify the midline
of the spine and mark the desired lumbar

Technique.
 Rapid sequence induction because
patient had mass 5X5 cm in abdomen
cavity.

Cricoid Pressure
(Sellick’s Maneuver)
 Is a method or preventing
regurgitation of stomach contents
into the larynx (wind pipe) during
intubation and induction of general
anesthesia .
 Usually for emergency case and full
stomach condition.

To perform Cricoid pressure
An assistant locate the position of the
cricoids cartilage before induction.
a. The cricoids cartilage is manually pushed back
to occlude the esophagus.
b. Use 3 fingers – thumb, index and middle finger
hold cricoids rings.
c. Index finger apply firm pressure 30-40 Newton
backward or downward to the anteriolateral aspect
as soon as anesthesia has been achieved.
d. Only release pressure after endotracheal tube
inflate and tube placement has been confirmed.

Advantages.
 Cricoids pressure can protect the
lung from aspiration of gastric
content.
 Can top up drugs and pain relief
because done under GA + epidural.
 Good quality of analgesia.

Disadvantage
1. Aspiration can occur if unproper
cricoid pressure.
2. Slow awakening after G.A.
3. All general anesthesia complication
can occur.

Complication:
 Larynggospasm  Vocal cord paralysis
 Bronchospasm  Arytenoids Cartilage
 Hypoxia Dislocation.
 Aspiration  Cauda equina
 Pharyngitis. syndrome.
 Laryngeal or Sub
 Transient neurological
Glottis Edema symptoms
 Arachnoiditis

Literature Review.
 Book of anesthesia and uncommon
diseases written by Katz / Benumuf /
Kadis. 3rd Edition describes …. The
technique of rapid sequences
intubation outlined here has proved to
be of great safety for patients at
significant risk of aspiration.

Literature Review.
 Krivak et al Gynecol Oncol. 2001; 83:89–
94. doi: 10.1006/gyno.2001.6334. [
PubMed] describes …. therapy of uterine
sarcomas remains surgery. Total
abdominal hysterectomy with bilateral
salpingo-oophorectomy (TAHBSO) can
be curative if disease was confined to the
uterus with five-year survival approaching
50%
General pre anaesthesia
preparation for patient
 Pre anaesthesia visit
 Nursing assessment
 Nursing assessment
 Physical Preparation
 Preparation on the day operation.

 Preparation of theatre
 Preparation of induction room
 Preparation of Anaesthesia Machine
 Preparation of haemodynamic monitoring
 Preparation of OT table and light.
 Preparation Of Other Equipment
 Suctions, Oxygen Deliver
 Scavenging
 Preparation Of Recovery Area.
 Temperature & Humidification

Receive patients from
Airlock to O.R.
 From arrival, greet patient to comfort

the patient – checked patient according
to the checklist

Air Lock
Care of patient
Pre
Apart from checklist, including:
1. Vital sign for data baseline taken

2. Keep all line safe and running well
3. Ensure all equipment for intubation
are checked ,available and ready
for used.

Intra
1. Ensure patient safety by locked the O.T. table at
all time.
2. Avoid any potential injury during positioning.
3. No excessive abduct of the hand during surgery
avoid brachial plexus injury.
4. Keep patient warm by warming mattress.
5. Continuously monitor vital sign.
6. Use warm fluid intravenously to prevent
hypothermia
7. Cover both eyes with eye pad.
8. Monitoring MAC value more than 1 to prevent
awareness.

Post
1. Secured the patient airway especially during
cleaning phase.
2. Assist the anesthetic confidently during the
extubation ensure all the item are ready and
functioning well to prevent complication e.g.
hypoxia.
3. Observed patient vital sign at all time so that any
complication can detect early.
4. Transfer patient from OT table to trolley safely
using slider when allowed by anesthetic.
5. Documentation.

Advice On Discharge
Advised patient post GA
1. Turn head lateral if patient vomit.
2. Not allowed oral and fluid intake until
instructed by doctor.
3. Observed and informed for bleeding and
pain on operation site.
4. Noticed immediately if symptom of drug
overdoses during infusion pethidine of
epidural.

Nursing Care Plan - PRE OP
A. Aspiration due to nausea and vomiting before induction
Objective: To prevent aspiration during induction.
Nursing intervention
1. Prepare MALES and difficult intubations item

2. Makesure intravenous line patent for injection of drugs
3. Suction function well to remove any secretions
4. Insert oropharyngeal airway to maintain airway
5. Preoxygenation 100% oxygen 15litre, 3 to 5 minutes via
mask tight seal.
6. Use technique rapid sequence induction .Applied proper
cricoids pressure. Only release once confirmation of tube
replacement are verified.
Evaluation: Intubations are smooth with no complication.

PRE OP
B. Anxiety due to operation
Objective: To reduced patient anxiety.
Nursing intervention
1. Encourage relatives to accompany patient to air lock.
2. Give emotional support to patient by spend time talking to
him so that he feel comfortable .
3. Identify patient worried by asking and observed from
patient face and try to overcome the worried.
4. Informed him regarding GA.
5. Makesure pre-med sedative T. Dormicum 7.5mg given on
night and before send patient to O.T.
6. Informed patient pain relief will be given after operation
and will be monitored at recovery before send to ward.
Evaluation: Patient less anxiety with haemodynamic stable

Nursing Care Plan - INTRA OP
A. Hipothermia due to long duration of operation – 4 hours.
Objective: To prevent hypothermia.
Nursing Intervention:
1. Monitor vital sign especially temperature using nasal
probe.
2. Warm patient with warming device e.g. warming
mattress.
3. Used warm intravenous solution .
4. Used warm irrigation for wash out along operation.
5. Keep ot temperature within 18˚c to 22˚c.
6. Avoid exposed other body parts except for surgery
Evaluation: Core body temperature within normal range 37˚c

INTRA OP
B. Potential injury due to supine position
Objective: To prevent any injury during operation and post op
1. Make sure O.T table always locked at all time avoid any
movement to o.t table which effect surgery
2. Armboard securely fixed avoid both hand fall down
3. No excessive abduct of left hand more than 90˚ avoid
brachial plexus injury.
4. Make sure no body parts outside the o.t table during
supine position avoid patient fall down.
5. Put pillow under both legs avoid nerves injury to the
heels.
Evaluation: No nerve injury and other injury throughout
operation and post op.

Nursing Care Plan - POST OP
A. Pain due to surgery
Objective: To reduced pain post operative.
1. Acces severity of pain using visual analogue pain score
2. Monitor vital sign especially blood pressure and heart rate
Blood pressure high and tachycardia shows patient in pain.
3. Attend and listen to patient complaint of pain. Give pain
relief if patient complaint of pain.
4. Teached patient on deep breathing exercise as divertional
theraphy.
5. Adviced patient avoid any rapid movement to the left hand
and left thigh which can cause pain.
Evaluation: No complaint of pain from patient and pain score is
zero.

Nursing Care Plan - POST OP
A. Pain due to surgery
Objective: To reduced pain post operative.
1. Acces severity of pain using visual analogue pain score
2. Monitor vital sign especially blood pressure and heart rate
Blood pressure high and tachycardia shows patient in pain.
3. Attend and listen to patient complaint of pain. Give pain
relief if patient complaint of pain.
4. Teached patient on deep breathing exercise as divertional
theraphy.
5. Adviced patient avoid any rapid movement to the left hand
and left thigh which can cause pain.
Evaluation: No complaint of pain from patient and pain score is
zero.

Discussion
Overall this case study I find that as
an assistant we must have skilled,
knowledgeable and always be
prepared physical and mental incase
if any problem arise.

Recommendation
Patients are often anxious about the
diagnosis, the findings and outcome of
the operation and about postoperative
pain. Egbert et al 1964 describes
Information and reassurance has been
shown to reduce the patient’s anxiety
and make it more manageable.

Conclusion
 Combined general anaesthesia with
epidural for patient under gone total
abdominal hysterectomy bilateral
Salpigo-oophorectomy very acceptable
for this case study. Epidural pethidine
post operation analgesic really working
in this case study. She had minimized
pain on two day post operation.


Case Study Majri

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Study Majri

Uploaded by

Copyright:

Available Formats

CASE STUDY ON THE USE OF

COMBINED GENERAL ANAESTHESIA

PPP MAJRI BIN ABAS

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

 Had abdominal swelling since June

December 8, 2021 GA+EPIDURAL

 No known medical illness

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

 Full Blood Count

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

 From arrival, greet patient to comfort

December 8, 2021 GA+EPIDURAL - TAHBSO

1. Vital sign for data baseline taken

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

1. Prepare MALES and difficult intubations item

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

December 8, 2021 GA+EPIDURAL - TAHBSO

You might also like