Cancer is extremely prevalent in today’s society with an estimated 2.5 million people having received and currently living with a cancer diagnosis in the UK (Maddams et al 2012).
Brain, Central Nervous System (CNS) or intracranial tumours make up only 3% of the overall cancer diagnosis, there were 10,624 new cases of brain, other CNS or intracranial tumours registered in the UK in 2013, with 5,164 (49%) being male and 5,460 (51%) being female (Cancer Research, 2013).
The focus of this written piece shall concentrate on the perioperative journey of a specific patient and will aim to critically evaluate the care given in each of the three areas; anaesthetic, scrub and in the post anaesthetic care unit (PACU). The patient selected underwent a Craniotomy and left temporal lesion biopsy, this patient was suffering from seizures, which were being controlled with Levetiracetam (Keppra), and also had raised intracranial pressure (ICP). The anaesthetic technique selected for this patient was total intravenous anaesthesia (TIVA), upon emergence and extubating the patient began having a seizure whereby the anaesthetist administered Diazepam, the patient was then transferred from theatre to recovery where they were observed until they could be released to the specialist neurological ward.
Each stage of the perioperative journey of this patient will be explored, and each intervention by the ODP will be critically examined using up to date resources where possible such as Cochrane reviews, journal articles, other online healthcare databases, journal articles, books, local and national guidelines as well as the guidelines set out by the Health and Care Professions Council (HCPC).
As the anaesthetic ODP having excellent communication skills is key in the preparation and setting up of the anaesthetic area and theatre, in order for a list to run smoothly, it is important that the ODP and anaesthetist know what they are doing, what order they are doing it in, and what they will need. This particular patient was to have Total Intravenous anaesthetic, therefore it is imperative that the ODP sources the correct pumps, line and the other intubating equipment in a timely manner so as to not cause delays. (Wicker & O’Neill, 2008; Hughes & Mardell, 2009).
Total intravenous anaesthesia (TIVA) is a technique whereby induction and maintenance of anaesthesia is achieved solely through an intravenous route and in the absence of any volatile agents including nitrous oxide (Sandham 2009). It has emerged in recent years that the combined use of Propofol as a hypnotic agent and Remifentanil as an analgesic and nociceptive agent have become the most popular choice of drugs for TIVA administration (Eikaas and Raeder, 2009).
In almost all Neuro procedures the patient will be induced using TIVA, this is because volatile agents used during anaesthesia such as Sevoflurane, Desflurane and Isoflurane increase intracranial pressure (ICP), increase cerebral blood flow (CBF) and reduce vascular resistance, and can also affect cerebral autoregulation which can make surgery much more difficult and dangerous (Magni et 2005, Strebel et al 1995 cited Cole et al 2007), which in a patient with an already raised intracranial pressure avoidance of increasing ICP further is advisable. Studies have indicated that Sevoflurane has least effect on ICP (De Deyene 2004 cited in Kulshrestha et al 2013) however the Oxford Handbook of Anaesthesia (2008) states that Isoflurane has least effect on ICP. The advantages of using TIVA for neuro procedures is as stated above, the drugs used don’t raise ICP or effect autoregulation, studies have shown that using TIVA reduces post-operative nausea and vomiting (PONV) (Fell & Kirkbride 2007; Allman & Wilson 2008; Eikaas and Raeder, 2009) the induction of the patient is rapid, with an equally rapid emergence from anaesthesia and with a minimal ‘hangover’ experience (Hughes & Mardell 2009). The disadvantages of using TIVA however can be pain on induction, increased cost compared to using volatile agents, recovery/emergence can be slow if the dose of propofol is not reduced in combination with the remifentanil, and interruption to the delivery of propofol may take longer to recognise meaning a patient may gain awareness during surgery (Allman & Wilson 2008; Hughes and Mardell 2009). In a systematic review conducted by Chui et Al (2014) to compare propofol vs volatile agents for maintenance of anaesthesia in patients undergoing elective craniotomies, it was concluded that other than PONV and slightly lower ICPs in the patients undergoing propofol maintained anaesthesia there could be no significant conclusion drawn as to which was method of anaesthesia should be used over the other, due to lack of studies conducted and lack of evidence of major clinical outcomes such as morbidity, mortality and neurological function, therefore no recommendations can be made as to which anaesthetic technique produces the best clinical outcomes, therefore it is down to anaesthetist choice as to which method is used. (Chui et Al 2014).
The patient once bought to the anaesthetic room having completed the pre-operative checklist with the anaesthetic ODP (Wicker & Neill, 2010), will be attached to routine monitoring. AAGBI guidelines (2007) recommend that all patients are monitored in the anaesthetic room prior to induction, this should include ECG, NIBP, SpO2, Capnography and Respiratory rate, the following should also be available; a nerve stimulator where a muscle relaxant is used and a means to monitor temperature. Craniotomy patients must also once anaesthetised have an arterial line inserted (Allman & Wilson, 2008; Hughes & Mardell 2009), this enables beat by beat monitoring of the blood pressure with a lot more accuracy than NIBP, it is also indicated for patients that may experience major haemodynamic instabilities such as large fluid shifts and blood loss such as patients undergoing craniotomies, an A-line also enables blood sampling for arterial blood gas analysis (Hughes & Mardell, 2009).
The choice of tube for this patient was a reinforced endotracheal tube (ETT), in most neurosurgical procedures a reinforced tube is advised to avoid kinking of the tube (Allman & Wilson 2008), they are commonly used for head and neck surgery due to the spiral of metal that runs through them, which means that for head and neck procedures where the head needs to be in turned or flexed into certain positions this is possible without occluding the tube and causing airway obstruction (Al-Shaikh & Stacey, 2003).
A urinary catheter is inserted for craniotomy cases, and this will have been discussed pre-operatively with the patient and surgeon, and the reasons as to why it needs to be inserted will be given. (Allman & Wilson, 2008; Hughes and Mardell 2009). Due to raised ICPs sometimes it is necessary to reduce the amount of fluid around the brain in order for the surgeons to maintain an optimum field for working (Cole et al 2007), if this is the case Mannitol will be given intravenously to reduce the pressure and volume of cerebrospinal fluid, due to the strong osmotic diuresis effect, it will increase urine output hence the insertion of a catheter (Smith et al 2011).
Once the patient has been anaesthetised and transferred onto the operating room table, it is the role of both the anaesthetic ODP and scrub ODP to make sure that they display and apply safe principles of positioning an anesthetised patient (Wicker & O’Neill, 2010), however it is the joint responsibility of the anaesthetist and the surgeon to ensure that overall the patient is positioned adequately for both surgical access and maximum exposure of the lesion, and also in a way that won’t cause difficulties for the anaesthetist (Baumer & Milligan, 2005; Rozet & Vavilava, 2007). During a craniotomy the patients head is maintained in a fixed position in a headrest that is attached to the theatre table, there are many different types of headrest available, however for this patient the Mayfield headrest (See Figure 1.) was used for the initial transfer from trolley to table, and once the surgeon was happy with the patients position on the table, the Three-Pin Mayfield skull clamp (See Figure 2.) pins were inserted into the patients skull with the clamp then being reattached to the headrest, rendering the patients head completely immobile. (Baumer & Milligan, 2005). The overall positioning of the patient is dependent on which part of the brain is going to be operated on, however in the case of this patient it is the Left Temporal Lobe, therefore the patient was in a supine position with the head turned to the left. When the fixation device is initially attached and tightened this can cause a profound stimulating effect and cause significant physiological effects on the patient such as hypertension and tachycardia, it is important to ensure that the anaesthetist is aware of when the surgeon is about to pin, so that they can pre-empt the hemodynamic effect and increase depth of anaesthesia accordingly, other disadvantages of using pins is bleeding from the insertion site, air embolisms, and scalp lacerations on removal of the device (Rozet & Valilava, 2007).
Once the patient has been positioned it is important for the ODP to then ensure that all pressure areas are protected using suitable equipment, ensuring that the arms are in a comfortable and natural position, using heel pads to ensure that the patients heels are raised off the theatre table mattress, that all cables and lines coming from the patient not directly on their skin, it is essential to perform these checks in order to prevent any nerve or pressure damage to the patients skin (Kumar, 1998; Wicker & O’Neill 2008; Trust Withheld 2015). In the case of this patient, they were supine, which meant the applying of heel pads, elbow gels and elbow pads, padding under the wires/cables. Gel rolls were also put underneath each forearm as they did not rest fully on the operating table. In doing these preventative methods each practitioner is complying with not only local and national guidelines, but also complying with the requirements set out by the HCPC in the Standards of Proficiency document.
During a craniotomy the surgeon will make an incision in the scalp, a bone flap is then created, the diseased or injured part of the brain is exposed, the pathological condition is removed, repaired or biopsied, the bone flap is then reattached and the incision closed (Baumer & Milligan, 2005). Suction and irrigation are essential during cranial surgery, as the skull does not expand to accommodate any increase in blood or tissue fluid, therefore the wound must be kept free of bleeding vessels. In patients with an already raised ICP this is even more important, so the use of Mannitol would aid in helping to keep the surgical site in the optimum state (Baumer & Milligan, 2005).
Once the operation is finished, the patient is transferred from the operating table to the patient bed, the anaesthetist then starts to decrease the infusions in order for the patient to start waking up. Once the anaesthetist is happy that the patient would be able to maintain their own airway if extubated the tube is removed. However a short while after extubating the patient began to have a seizure. At first it was almost undetectable, and the anaesthetist monitored the patient for a minute, it then became obvious that the patient was indeed having a seizure, the surgeon was informed and asked to come back into theatre. The reason for the patient to have this seizure could be of numerous reasons, as stated earlier the patient was already taking the medication Levetiracetam (Keppra) to control the seizures they were experiencing due to the lesion on their brain. It is widely acknowledged that patients suffering with epilepsy may be prone to seizing during the rapid emergence from a propofol induction (Allman & Wilson 2008), reactions to anaesthetic drugs such as propofol, enflurane and local anaesthetics can also cause seizures (Hughes & Mardell, 2009), however the most common reason for having a seizure after neurosurgery is because of the surgery itself, all neurosurgical patients have an increased risk of having a post-operative seizure. (Allman & Wilson, 2008; Hughes & Mardell 2009). First line of treatment of seizure post operatively is benzodiazepines such as Diazepam, which has anticonvulsant and analgesic effects, second line treatment would be to administer Phenytoin which is another anticonvulsant drug, only in the worst case scenarios should propofol be used and if so reintubation, ventilation and then transferral to an intensive care unit is preferable. (Allman et al, 2005; 2005; Allman & Wilson, 2008; Hughes & Mardell, 2009). This patient needed only first line treatment as the anaesthetist administered Diazepam which stopped the patient from convulsing.
Upon arrival in the post anaesthetic care unit (PACU), it is essential that the recovery practitioner makes an initial assessment of the patient using the ABCDE approach; airway, breathing, circulation, drugs, drips, drains and dressings, extras such as measuring the patients temperature, checking the patients’ blood glucose levels if the patient is a diabetic, it is essential that on arrival to the PACU that a formal handover is given by the anaesthetist and the scrub practitioner, this aids in continuity of care and allows for the communication of details such as the patients’ procedure and treatment in the operating room, any medications given before, during and after surgery, and things like the patient being hard of hearing, epileptic or diabetic. The recovery practitioner should only receive handover when they are completely satisfied that the patients’ condition is stable (Wicker & O’Neill 2010; Hatfield, 2014).
With patients that have had neurosurgical procedures such as this one an extra requirement of the recovery practitioner is to perform Neurological observations which include Glasgow Coma Scale (GCS), pupillary reaction, motor function, and vital signs (Mooney & Comerford, 2003). It cannot be stressed enough the importance of undertaking neurological observations (Dawes et al, 2007), as it can identify the improvement or deterioration in a patients’ condition (Lindsay et al 1997). The GCS is a way of demonstrating a patients consciousness by their ability to perform three activities, these are; eye opening, verbal response and motor response. Each activity is given a score (see figure 4) with the highest obtainable score being 15 and the lowest a GCS of 3, a score of 15 equates to a person who is orientated, can obey commands and open his or her eyes spontaneously (Trust withheld 2015; Mooney & Comerford, 2005).
Eye opening should be a spontaneous response to the patient being approached, it should be determined whether the patients’ eyes open in response to speech or painful stimuli, it they do open it should be noted that this does not indicate that the patient is fully aware and is orientated as some patients that have suffered head injuries may have spontaneous blinking and eye movement (Muxlow, 2000 cited Mooney & Comerford, 2005). Verbal response determines the level of consciousness of the patient, a patient who is orientated will know their date of birth, their name and what year it is, however a confused patient may be able to hold a conversation yet may give incorrect or not know the answers to the above questions. The motor response of a patient is assessed by giving them verbal commands such as ‘squeeze my hand’ (both sides), ‘stick out your tongue’ or ‘lift your legs off the bed’, the limbs of the patient must be observed for any weakness and the strength recorded. If the patient doesn’t obey the commands the application of painful stimuli and the response to this stimuli is assessed.
Advantages of using GCS is that it is widely known and an accepted tool in the assessment of neurological observations, however inaccurate and inconsistent recordings can have a detrimental effect on the patients wellbeing (Mooney & Comerford, 2005). Limitations that can occur when using GCS can be the failure to recognise that a change in the patients’ conscious level can actually occur before there are any changes to the vital signs such as pupillary response or blood pressure. Other limitations of using the GCS when assessing neurological function is that it doesn’t take into consideration analgesia/sedation, other medications, intubation and ventilation, alcohols and other intoxications, people who can only speak and understand another language, people with learning difficulties and people with speech difficulties such as dysphasia (Mooney & Cromerford,2005; Randle et al 2009; Trust withheld, 2015)
Pain management in the PACU is important as it will encourage a rapid recovery (McMain, 2008 cited Wicker & O’Neill, 2008), appropriate assessment of pain is imperative and the patients perception of the amount of pain they are in must be believed (Hughes & Mardell, 2009). There are several ways to assess pain in recovery; verbal rating scale (VRS), numerical rating scale (NRS), visual analogue scale (VAS) and behavioural rating scale (see figure 3), each scale has its own advantages and disadvantages, the scale used for this patient was the NRS. The NRS is a scale where the numbers 0-5 or 0-10 with 0 being no pain and 5 or 10 being the absolute worst pain possible, it should be explained to the patient what each number means and for them to choose where they best fit on the scale. If this pain scale is the one utilised then a pain score of 2 and below should be aimed for when using 1-5 and a score of 4 and below should be aimed for when using 1-10 (Randle et al 2009; Hatfield 2014). When making an assessment of pain it should be done when the patient is relaxed as anxiety can increase the patients’ perception of pain. Disadvantages of the NRS can be using the pain scale isolation to the other observations, a patient that is scoring themselves 10/10 for pain but is sitting up, has normal observations and is holding a conversation is highly unlikely to be a 10 on the pain scale, however another pitfall of this scale is not believing where the patient has rated themselves (Kumar, 1998; Hughes & Mardell, 2009; Randle et al, 2009; Hatfield, 2014).
The treatment of post-operative pain is essential before the patient can be discharged back to a ward or specialist unit as it may be difficult to achieve on the ward or when pain becomes more established, inadequate pain relief can have significant delays on long term post-operative recovery (Wicker & O’Neill 2009). The choice of postoperative analgesia is important in ensuring the patient is comfortable, there are three different types of pain relief that can be used in PACU these are; opioids including patient controlled analgesia such as PCAs such as morphine, codeine etc, non-steroidal anti-inflammatory drugs such as ibuprofen, paracetamol and diclofenac, and adjuvant drugs such as clonidine and ketamine. The recovery ODP needs that they check all relevant documentation regarding drugs already given to the patient to avoid giving them more of the same (Wicker & O’Neill, 2009). For this patient the anaesthetic recovery practitioner did not need to administer any pain relief before discharge from the area, as the patient had received diazepam as well as receiving paracetamol during surgery. The anaesthetist however did prescribe morphine to be administered if necessary, however opioids do come with side effects that may lead to respiratory depression, CO2 retention, increased intracranial pressures and increased blood flows, which in a post-craniotomy patient it is important to minimise the increase of intracranial pressures. Despite this however morphine is commonly prescribed for these patients but should be used on a need to basis (Santos et al 2013).
In conclusion, it is important to ensure that each aspect of patient care is individualised to their specific needs, in this patient in particular with the underlying condition of having seizures it was important to understand the condition, the medications and how other drugs can affect and potentially encourage more seizures, it was also equally important for this information to be passed on to the recovery member of staff, due to the possibility of the patient having another seizure either whilst in recovery or once they are on the unit. Using the GCS in recovery on a neuro is an excellent way of establishing consciousness and motor responses, other than the pitfalls already mentioned it is quite accurate in determining whether the surgery has been beneficial i.e in a patient with decreased GCS beforehand or like in the case of this patient whether their condition has actually worsened due to the procedure.
Overall this assignment sought to look at a patient journey and the specific interventions and treatments in each of the three perioperative areas, due to the word restriction not much depth could be achieved in each of the three areas, however the most important factors for giving optimum care to a neuro patient were identified and discussed, therefore providing an insight into the post-operative journey of a specific patient whilst also identifying the role of the ODP.
Association of Anaethetists of Great Britain and Ireland (AAGBI) (2004) Recommendations for standards of monitoring during anaesthetics and recovery. AAGBI, London
ALLMAN K & WILSON I (2008). Oxford Handbook of Anaesthesia (second edition). Oxford: Oxford University Press.
AL-SHAIKH B & STACEY S (2003). Essentials of Anaesthetic Equipment (second edition). London: Churchill Livingstone
Baumer C & Milligan J. (2005). Neurosurgery. In: Fuller, A Surgical Technology Principles and Practice. 4th ed. Missouri: Elsevier Saunders. ..
Chui, J, Mariappan, R, Mehta,J, Manninen,P, Venkatraghavan, L. (2014). Comparison of propofol and volatile agents for maintenance of anesthesia during elective craniotomy procedures: systematic review and meta-analysis. Canadian Journal of Anesthesia. 61 (.), 347-356.
Cole CD, Gottfried OD, Gupta DK, Couldwell WT. (2007). Total intravenous anaesthesia: advantages for intracranial surgery. Neurosurgery. 61 (.), 369-377.
Dawes E, Lloyd H, Durham L (2007) Monitoring and recording patients’ neurological observations. Nursing Standard. 22, 10, 40-45.
Eikaas H & Raeder J. (2009). Total intravenous anaesthesia techniques for ambulatory surgery. Current Opinion in Anaethesiology. 22 (.), 725-729.
Fell, D & Kirkbride, D. (2007). The practical conduct of anaesthesia. In: Aitkenhead, A.R., Smith G., Rowbotham, D.J. Textbook of anaesthesia. 5th ed. Edinburgh: Churchill Livingstone. 297-314.
HATFIELD A (2014). The Complete Recovery Room Book.(Fifth edition) Oxford; Oxford University Press
HEALTH PROFESSIONS COUNCIL (2014) The Standards of Proficiency for Operating Department Practitioners. London, HPC.
Hughes & Mardell,A (2009). Oxford Handbook or Perioperative Practice. Oxford: Oxford University Press.
Kulshrestha A, Bajwa S. (2013). Anaesthetic Considerations in Intracranial Neurosurgical Patients. Journal of Spine & Neurosurgery.
KUMAR B (1998). Working in the Operating Department. London: Churchill Livingstone
Lindsay KW, Bone I, Callander R (1997) Neurology and neurosurgery illustrated. London, Churchill Livingstone
Maddams J, Moller H, Utley M. (2012). Projections of Cancer prevalence in the United Kingdom 2010-2040. British Cancer Journal. 107 (.), 1195-1202.
Mooney G, Comerford DM (2003) Neurological observations. Nursing Times 99(17): 24-25
RANDLE J, COFFEY F & BRADBURY M (2009). Clinical Skills in Adult Nursing. Oxford: Oxford University Press.
Rozet, I, Vavilala, M. (2007). Risks and Benefits of Patient Positioning During Neurosurgical Care. Anesthesiol Clin. . (.), 631-x.
Sandham J. (2009). Total Intravenous Anaesthesia. Available: http://www.ebme.co.uk/articles/clinical-engineering/95-total-intravenous-anaesthesia-tiva. Last accessed 15th March 2016.
Santos,C, Pereira,C, Otávio de Araújo, D, Silva,Paixão P, . (2013). Options to manage post-craniotomy acute pain: no protocol available. Revista Chilena de Neurocirugía . 39 (.), 22-27.
SMITH S, SCARTH E & SASADA M. (2011). Drugs in Anaesthesia and Intensive Care (fourth edition). Oxford: Oxford University Press.
Unknown. (2015). Brain, other CNS and intracranial tumour incidence statistics. Available: 10,624 new cases of brain, other CNS or intracranial tumours registered in the UK in 2013, with 5,164 (49%) being male and 5,460 (51%) being female (Cancer Research, 2013). . Last accessed 15th March 2016.
WICKER, P. & O’NEILL, J. (2010). Caring for the Perioperative Patient. Oxford:
Figure 1: Mayfield headrest (image taken from Intergra limit uncertainty)
Figure 2: Three-Pin Mayfield Skull clamp
Figure 3: Numerical and Verbal Rating scales (images taken from notrightinthehead)
...(download the rest of the essay above)