28 April 2011 GA+EPIDURAL - TAHBSO



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.

28 April 2011



General objective 

By doing this case study on the use of combined general anaesthesia with epidural for patient under gone total abdominal hysterectomy bilateral SalpigoSalpigooophorectomy is to ensure that all preparations for patient undergone surgery will be successful and reduce pre, intra and postoperative complications

28 April 2011


Specific Objective    To participate in technique using in giving anaesthesia. GA+EPIDURAL . To improved skilled when performing cricoids pressure and the important of cricoids pressure. intra and post using nursing process.TAHBSO 28 April 2011 4 . To provide care of patient for pre. rapid sequence induction.

Respiratory System 28 April 2011 GA+EPIDURAL .Anatomy and physiology of the system involved.TAHBSO 5 .

TAHBSO 6 .Anatomy Epidural Space 28 April 2011 GA+EPIDURAL .

Anatomy of female reproductive system 28 April 2011 GA+EPIDURAL .TAHBSO 7 .

TAHBSO 8 . : 590218105044 NO. RN. Age Sex Race 28 April 2011 : 1171118 : 49 years old : Female : Malay GA+EPIDURAL . RN.Patient Particular Name : Mrs S IC NO.

TAHBSO 9 .Present History  Had abdominal swelling since June 2007 Only sought 7 times On April 2008 diagnosed as ovarian carcinoma   28 April 2011 GA+EPIDURAL .

Past Medical And Surgical History     No known medical illness No history of chest pain/orthopnea pain/orthopnea No known allergy of drug and food Known case of migraine especially pre menstrual last attack 2003.TAHBSO 10 . much better 28 April 2011 GA+EPIDURAL . now 2003.

full term spontaneous virginal delivery 28 April 2011 GA+EPIDURAL .  No surgical history Obstetric history Para 3.TAHBSO 11 .

Treatments  Tablet Propanolol 40 mg. BD for migraine prophylaxis 28 April 2011 GA+EPIDURAL .TAHBSO 12 .

TAHBSO 13 .Investigations      Full Blood Count BUSE RBS ECG Chest X-Ray 28 April 2011 GA+EPIDURAL .

TAHBSO 14 .Type Of Operation Planned  Combined general anaesthesia with epidural 28 April 2011 GA+EPIDURAL .

so you do not feel or remember anything that happens. General anaesthesia is commonly produced by intravenous drugs or inhaled gasses. The anesthetized brain does not form memories or respond GA+EPIDURAL -signals.Definition of General anaesthesia General anaesthesia is a treatment that puts you to sleep during medical procedures. to pain TAHBSO 28 April 2011  15 .  The "sleep" you experience under general anaesthesia is different from regular sleep.

You will have no pain. General Anaesthesia is the most common type of anaesthesia for surgery. You will remember little about the surgery or recovery period.TAHBSO 28 April 2011 16 . Injecting medicines into a vein. You will be in a sleep state during the surgery. The selection of which drugs are used depends on your physical condition and the type of surgery you are having. Many aesthetic drugs are now available. There are several methods of giving general anaesthesia. GA+EPIDURAL . or having you breathe a gas from the anaesthesia machine administers usually general anaesthesia. and they help make your anaesthesia safer than ever before.

Definition of Regional Anaesthesia  Regional Anaesthesia is used to numb only a specific part of the body. where it blocks pain sensations. epidural. 28 April 2011 GA+EPIDURAL .TAHBSO 17 . There are many types of regional anaesthesia. The most common are: spinal. and Bier blocks. A local aesthetic (numbing medicine) is injected into the area.

Since autonomic.TAHBSO 28 April 2011 18 . thoracic. it can be used for surgical anaesthesia where relaxation is required. GA+EPIDURAL . sensory and motor block occur with an epidural. or lumbar levels. An epidural block can be performed at cervical. Epidural anaesthesia is a neuraxial technique offering wide range of applications for procedures below the neck level.

operation. hours. GA+EPIDURAL .TAHBSO 28 April 2011 19 . Patient treats as full stomach condition because she had mass in abdomen cavity. cavity. Long time operation 4 hours.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.

Indication of Epidural  postoperative pain control 28 April 2011 GA+EPIDURAL .TAHBSO 20 .

 Proper size facemask ± tight seal cover mouth and nose.TAHBSO 21 .  Lubricant ± with lignocaine gel  28 April 2011 GA+EPIDURAL .  Laryngoscope with curved blade (Macintosh) in which the bulbs works. 4 and 5.checked for leaking  Airway ± oropharyngeal airway ± 3 sizes ± size 3.Preparations  Preparation of equipment (MALES) GA machine .

5mm. 8.TAHBSO 22 .  Stethoscope to check correct placement of the tube by listening for breath sound.5mm.  Suction machine function.  Stylet as guide for endotracheal tube  Syringe 20ml to inflate the cuff once the tube is in place. to remove secretions.  28 April 2011 GA+EPIDURAL .  Plaster/string to anchor endotracheal tube at the level of the patient teeth.Endotrachel various sizes ± prepare in 3 sizes ± 7.0mm and 8.

TAHBSO 23 .28 April 2011 Preparation for Intubation GA+EPIDURAL .

28 April 2011 G.A.TAHBSO 24 . Machine GA+EPIDURAL .

Absorber 25 .Breathing 28 April 2011 Circuit and CO2 TAHBSO GA+EPIDURAL .

 Injection Sux (scoline)  Injection Esmeron 60 mg 28 April 2011 GA+EPIDURAL .TAHBSO 26 .  Injection Propofol 50 mg  Injection Fentanyl100 mg  Muscle relaxant. Preparation of drugs.  Induction agent.

5 mg  NSAID  Injection Parecoxib 40 mg (Dynastat)  Injection Dexamethasone 4 mg  Antibiotic  Injection Cefuroxime 1.TAHBSO 27 . Reversal.5 gm 28 April 2011 GA+EPIDURAL .  Injection Atropine 1 mg  Injection Neostigmine 2.

TAHBSO 28 .28 April 2011 Preparation of Drugs GA+EPIDURAL .

28 April 2011 Preparation of Epidural GA+EPIDURAL .TAHBSO 29 .

 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. 28 April 2011 GA+EPIDURAL . Give emotional support by listening patient express regarding operation. Answer all questions or any doubt so that patient understands and less worried.TAHBSO 30 .

This position permits better visualization of the glottis and vocal cord and allows easier passage of the endotracheal tube.TAHBSO 31 .Position of the patient ± sniffing position / morning sniff position serve to align the oral. so that the passage from the lip to the glottic opening is almost a straight line.  Ensure good intravenous line and patent.  28 April 2011 GA+EPIDURAL . pharyngeal and laryngeal axis.  Vital sign taken as baseline data.

 Put patient on warming device or warm blanket to prevent hypothermia.TAHBSO 32 . Attached all monitor such as SPO2 probe  make sure proper position of SPO2 infrared and photodetacted are parallel for better reading.proper size 2/3circumference upper arm. Blood Pressure cuff . ECG electrodes attached.  28 April 2011 GA+EPIDURAL .

TAHBSO 33 .Sitting Position for Epidural 28 April 2011 GA+EPIDURAL .

 The shoulders are ³hunched´ 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  28 April 2011 GA+EPIDURAL .TAHBSO 34 .The legs are allowed to hang over the edge of the bed with the feet supported by a stool.

 Rapid sequence induction because patient had mass 5X5 cm in abdomen cavity.TAHBSO 35 .Technique. 28 April 2011 GA+EPIDURAL .

Usually for emergency case and full stomach condition.TAHBSO 36 .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 . 28 April 2011 GA+EPIDURAL .

TAHBSO 37 .28 April 2011 GA+EPIDURAL .

28 April 2011 GA+EPIDURAL .TAHBSO 38 .

b. Only release pressure after endotracheal tube inflate and tube placement has been confirmed. c.TAHBSO 39 .To perform Cricoid pressure An assistant locate the position of the cricoids cartilage before induction. Use 3 fingers ± thumb. a. Index finger apply firm pressure 30-40 Newton backward or downward to the anteriolateral aspect as soon as anesthesia has been achieved. 28 April 2011 GA+EPIDURAL . index and middle finger hold cricoids rings. d. The cricoids cartilage is manually pushed back to occlude the esophagus.

Can top up drugs and pain relief because done under GA + epidural.    Cricoids pressure can protect the lung from aspiration of gastric content.Advantages. 28 April 2011 GA+EPIDURAL .TAHBSO 40 . Good quality of analgesia.

Slow awakening after G. 28 April 2011 GA+EPIDURAL . 2.A.TAHBSO 41 . All general anesthesia complication can occur. 3.Disadvantage Aspiration can occur if unproper cricoid pressure. 1.

Cauda equina syndrome.Complication:       Larynggospasm Bronchospasm Hypoxia Aspiration Pharyngitis.TAHBSO 42 . Transient neurological symptoms Arachnoiditis 28 April 2011 GA+EPIDURAL . Laryngeal or Sub Glottis Edema      Vocal cord paralysis Arytenoids Cartilage Dislocation.

Literature Review. 28 April 2011 GA+EPIDURAL .  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.TAHBSO 43 .

Literature Review. Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) can be curative if disease was confined to the uterus with five-year survival approaching 50% GA+EPIDURAL . [PubMed] describes «. 83:89± 94.TAHBSO 28 April 2011 44 .1006/gyno.6334. 2001.2001.  Krivak et al Gynecol Oncol. therapy of uterine sarcomas remains surgery. doi: 10.

General pre anaesthesia preparation for patient      Pre anaesthesia visit Nursing assessment Nursing assessment Physical Preparation Preparation on the day operation.TAHBSO 45 . 28 April 2011 GA+EPIDURAL .

Temperature & Humidification GA+EPIDURAL . Oxygen Deliver Scavenging Preparation Of Recovery Area.TAHBSO 28 April 2011 46 . Preparation Of Other Equipment  Suctions. Preparation of theatre         Preparation of induction room Preparation of Anaesthesia Machine Preparation of haemodynamic monitoring Preparation of OT table and light.

R.  From arrival.Receive patients from Airlock to O.TAHBSO 47 . greet patient to comfort the patient ± checked patient according to the checklist 28 April 2011 GA+EPIDURAL .

28 April 2011

Air Lock



Care of patient

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.

28 April 2011



Keep patient warm by warming mattress. Monitoring MAC value more than 1 to prevent awareness. Continuously monitor vital sign. 8.Intra 1. Use warm fluid intravenously to prevent hypothermia 7. Avoid any potential injury during positioning. 5. No excessive abduct of the hand during surgery avoid brachial plexus injury. 28 April 2011 GA+EPIDURAL . 2. 6. table at all time.T. Cover both eyes with eye pad. 4.TAHBSO 51 . Ensure patient safety by locked the O. 3.

Transfer patient from OT table to trolley safely using slider when allowed by anesthetic. Observed patient vital sign at all time so that any complication can detect early. 4. 28 April 2011 GA+EPIDURAL .Post 1.TAHBSO 52 . 5. hypoxia.g. Assist the anesthetic confidently during the extubation ensure all the item are ready and functioning well to prevent complication e. 2. Secured the patient airway especially during cleaning phase. 3. Documentation.

Observed and informed for bleeding and pain on operation site. Noticed immediately if symptom of drug overdoses during infusion pethidine of epidural.TAHBSO 53 . Not allowed oral and fluid intake until instructed by doctor. 3. 2.Advice On Discharge Advised patient post GA 1. 28 April 2011 GA+EPIDURAL . 4. Turn head lateral if patient vomit.

Preoxygenation 100% oxygen 15litre. Use technique rapid sequence induction . Prepare MALES and difficult intubations item 2. Nursing intervention 1.Applied proper cricoids pressure.Nursing Care Plan .PRE OP A. Suction function well to remove any secretions 4. 3 to 5 minutes via mask tight seal. Insert oropharyngeal airway to maintain airway 5.TAHBSO Evaluation: Intubations are smooth with no 54 . Only release once 28 April confirmation of tube replacement are verified. 2011 GA+EPIDURAL . 6. Aspiration due to nausea and vomiting before induction Objective: To prevent aspiration during induction. Makesure intravenous line patent for injection of drugs 3.

Anxiety due to operation Objective: To reduced patient anxiety.PRE OP B. 3. Encourage relatives to accompany patient to air lock. Dormicum 7. Informed him regarding GA.T. Nursing intervention 1. Give emotional support to patient by spend time talking to him so that he feel comfortable . Evaluation: Patient less anxiety with haemodynamic 28 April stable 2011 GA+EPIDURAL . Makesure pre-med sedative T. 4.TAHBSO 55 .5mg given on night and before send patient to O. 5. 2. 6. Identify patient worried by asking and observed from patient face and try to overcome the worried. Informed patient pain relief will be given after operation and will be monitored at recovery before send to ward.

3.INTRA OP A. 6. 4.TAHBSO 37Ûc 56 . Monitor vital sign especially temperature using nasal probe. Used warm irrigation for wash out along operation. Avoid exposed other body parts except for surgery Evaluation: Core body temperature within normal range 28 April 2011 GA+EPIDURAL . Hipothermia due to long duration of operation ± 4 hours. Nursing Intervention: 1. Warm patient with warming device e.Nursing Care Plan .g. Used warm intravenous solution . Objective: To prevent hypothermia. 2. 5. Keep ot temperature within 18Ûc to 22Ûc. warming mattress.

Make sure O. Evaluation: No nerve injury and other injury throughout operation and post op. No excessive abduct of left hand more than 90Û avoid brachial plexus injury. Armboard securely fixed avoid both hand fall down 3.t table during supine position avoid patient fall down.t table which effect surgery 2.TAHBSO 57 . 28 April 2011 GA+EPIDURAL . Make sure no body parts outside the o. 4. Potential injury due to supine position Objective: To prevent any injury during operation and post op Nursing Intervention: 1.INTRA OP B. Put pillow under both legs avoid nerves injury to the heels. 5.T table always locked at all time avoid any movement to o.

3. 4. Nursing Intervention: 1. Attend and listen to patient complaint of pain.POST OP A.Nursing Care Plan . Pain due to surgery Objective: To reduced pain post operative. 5. 2011 GA+EPIDURAL . Evaluation: No complaint of pain from patient and pain 28 April score is zero. Adviced patient avoid any rapid movement to the left hand and left thigh which can cause pain. Acces severity of pain using visual analogue pain score 2. Give pain relief if patient complaint of pain.TAHBSO 58 . Teached patient on deep breathing exercise as divertional theraphy. Monitor vital sign especially blood pressure and heart rate Blood pressure high and tachycardia shows patient in pain.

5.POST OP A. 4. Pain due to surgery Objective: To reduced pain post operative. 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 28 April score is zero. Teached patient on deep breathing exercise as divertional theraphy. Monitor vital sign especially blood pressure and heart rate Blood pressure high and tachycardia shows patient in pain. Nursing Intervention: 1. Attend and listen to patient complaint of pain.Nursing Care Plan .TAHBSO 59 . Give pain relief if patient complaint of pain. Acces severity of pain using visual analogue pain score 2. 2011 GA+EPIDURAL . 3.

TAHBSO 60 . knowledgeable and always be prepared physical and mental incase if any problem arise. 28 April 2011 GA+EPIDURAL .Discussion Overall this case study I find that as an assistant we must have skilled.

28 April 2011 GA+EPIDURAL . the findings and outcome of the operation and about postoperative pain.TAHBSO 61 . Egbert et al 1964 describes Information and reassurance has been shown to reduce the patient¶s anxiety and make it more manageable.Recommendation Patients are often anxious about the diagnosis.

GA+EPIDURAL .Conclusion  Combined general anaesthesia with epidural for patient under gone total abdominal hysterectomy bilateral Salpigo-oophorectomy very acceptable for this case study. She had minimized pain on two day post operation.TAHBSO 28 April 2011 62 . Epidural pethidine post operation analgesic really working in this case study.

TAHBSO 63 .28 April 2011 GA+EPIDURAL .

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