SID NO: 1006843

Anaesthetic Case Study

Functional Endoscopic Sinus Surgery, Septoplasty

and Sub-mucous diathermy

Introduction

This is a case study based on the anaesthetic process of a patient undergoing functional

endoscopic sinus surgery (FESS), septoplasty and sub-mucous diathermy (SMD). The

author is a first year trainee operating department practioner who reflects the patient’s

journey through anaesthesia from pre-operative assessment to the perioperative process,

whilst giving the panoramic view of holistic approach to the care the patient receives. For the

purpose of this study, the patient is identified as Mr X. This is to maintain patient

confidentiality and Data protection. The Health Care and Professions Council (HCPC) (2012)

suggests that anything that could be used to identify a service user from confidential

information should not be used in any student assessment. They further state that as

professionals, any personal information shouldn’t be given to anyone who is not entitled to

access it. The author’s placement hospital’s policy also supports the same principle.

Handling personal information about individuals, have a number of legal obligations calling

the need to protect that information under the Data Protection Act (1998). A verbal consent

to do this case study was taken by the author in the presence of the anaesthetist and the

author’s mentor.

Patient Profile

The patient was a retired 65year old male who lived with his wife. He was 6 feet tall,

weighing 83 Kilogrammes and had a body mass index of 25.1. Mr X was a non-smoker and

drank an average of 2 units of alcohol per day. He had no known allergies and had been

taking Etoricoxib, a Non-Steroidal Anti-inflammatory Drug (NSAID) that selectively blocks the
action of the enzyme Cyclo-Oxygenase 2 (COX-2) (Martin 2010) for a pre-existing condition

of Osteo-arthritis. Mr X had stopped taking these two weeks prior to the surgery date as

instructed by the surgeon. The side effects of this drug include atrial fibrillation, transient

ischaemic attack and chest pain which compromises patient safety during the perioperative

process (British National Formulary (BNF) 2010). He had previous surgeries which included

a shoulder and knee arthroscopy, haemorrhoids and an appendectomy with no adverse

reaction to anaesthesia. Mr X presented himself to his general practitioner with symptoms of

pain, tenderness and nasal obstruction with the presence of nasal discharge, facial pain,

headache and recurrent throat infection. His symptoms persisted with chronic sinusitis.

These develop for several reasons including inadequate treatment of an acute episode,

septal deviation or nasal polyps that prevent adequate drainage of the sinuses, pollution or

allergic nasal disease (Alexander 2004). An assessment was made by the medical

practitioner of the symptoms, and surgery was the chosen plan of treatment.

Pre- assessment

On the day of the surgery, the author accompanied the anaesthetist to visit Mr X to do the

vital pre-assessment checks. These are done to assess the patient’s physical condition and

the anaesthetic risk in relation to the proposed surgery (Robinson et al 2012). The

anaesthetic technique, postoperative care, analgesia and anti-emetics were discussed. The

patient’s Mallampati classification was conducted to assess any difficult endotracheal

intubation. It is graded from grades I-IV, grades III and IV suggest difficult intubation

(Aitkenhead et al, 2007). Mr X was asked to open his mouth and maximally protrude his

tongue. The view of the pharyngeal structures was noted to be a grade II. The patient’s

thyromental distance, the distance between the bony point of the chin and the prominence of

the thyroid cartilage when the head is fully extended on the neck was measured to be 6.5

centimetres. A distance greater than 7 centimetres indicates a difficult intubation (Gwinnutt

2008). The anaesthetist suggested we use a size 5 reinforced laryngeal mask for this

patient. This was communicated to the operating department practitioner before

anaesthesia, ensuring any necessary extra equipment such as difficult intubation trolley and

fibre optic laryngoscopes were ready and available.

The author asked the patient when he last ate and drank. Generally for elective surgery,

patients are asked to fast prior to surgery to minimise the volume of stomach contents and

the associated risk of regurgitation and pulmonary aspiration after induction of anaesthesia.

Adults should not eat solids for 6 hours before an operation and all patients can have clear

fluids for up to 2 hours before surgery. (Nathanson 2007)

The American Society of Anaesthesiologists (ASA) uses a scale for estimating risks to

classify a patient’s physical status by assigning a category from I to V. These are dependent

on effects caused by either the disease process for which the surgery is being performed or

any pre-existing conditions. ASA I is a healthy patient. ASA II is a patient with mild to

moderate systematic disease. ASA III patient has a severe systematic disease. ASA IV

patient has severe systematic disease which is incapacitating and is a constant threat to life

and ASA V is where the patient is not expected to live for 24hours without the surgery

(Nathanson 2007). Mr X was given an ASA physical status as ASA II. The vital readings for

the patient were also noted as per the chart below:

Heart Rate 55bpm

Blood Pressure 160/78mmhg

Oxygen Saturation 98%

This information and classification would later be discussed with the surgical team when the

World Health Organisation (WHO) Surgical Safety Checklist (2008) is completed prior to the

surgery. The Surgical Safety Checklist is a part of the initiative “The Safe Surgery Saves

Lives” programme introduced by the World Alliance for Patient Safety, to improve

perioperative safety practice and to ensure that the correct patient is for the correct surgical
procedure. It also ensures that effective communication between the perioperative team is

met and reduces the adverse consequences of unsafe healthcare. (Wicker, 2010)

By undertaking the pre-operative visit on the day of the surgery, the anaesthetic team

minimised the patient’s anxieties before anaesthesia, and enabled them to develop a rapport

with the patient, reducing his fears. Cemille et al (2007) suggests that anxiety and fear is

caused by a lack of trust in the surgical team and a familiar face in the theatre may reduce

that.

Anaesthetic room and equipment

The operating department practitioner, the anaesthetist and the author performed checks in

according to Association of Anaesthetists of Great Britain & Ireland 2012 (AAGBI) safety

guideline, ensuring the anaesthetic machines in the anaesthetic room and operating theatre

were in safe working order. The anaesthetic machines delivers gas and vapour

concentrations continuously and accurately at safe pressures. It incorporates components

including gas supplies, pressure regulators and gauges, flowmetres, vaporisers and

common gas outlet (Al-Shaikh et al 2007)

The gas supply to the anaesthetic machine is supplied from the pipelines or the gas

cylinders. The pipeline outlets are made out of copper and the pipeline outlet system is

identified by name, colour and shape (Robinson et al 2012). Oxygen is white, Nitrous Oxide

is blue and the suction pipeline is yellow. These have non-interchangeable Schrader valve

connections to stop misconnection. When checking the pipelines, it should be visually

observed that the connections are correct and a “tug test” on each pipeline done to show

that it is secure. The pipeline pressure gauges on the anaesthetic machine should indicate a

pressure of 400-500kPa (Aitkenhead et al, 2007). The gas cylinders comprise of a body and

shoulder that contain threads into which a pin index valve block is fitted. The pin index

system prevents inter-changeability of cylinders when attaching them to the anaesthetic

machine. On each cylinder is an arrangement of three holes specific to the gas that
corresponds to the pin on the machine. A Bodok Seal (washer) is on the top pin to stop leaks

occurring between the cylinder and machine (Robinson et al 2012). The gas cylinders are

colour coded according to the gas supplied, Oxygen which is stored as a gas, is black with

white shoulder. Nitrous Oxide is stored as a liquid and is blue with blue shoulder. Medical air

is grey with white and black shoulder (Aitkenhead et al, 2007).

Pressure regulators are used on anaesthetic machines to reduce the high pressure of gas

cylinder to a safe working level of about 400kPa which is similar to pipeline pressure (Al-

Shaikh et al 2007). Regulators protect the components of the anaesthetic machine against

pressure surges. Cylinder pressure is regulated by a pressure reducing valve. These are

often fitted on the downstream side of regulators to allow escape of gas if the regulators

were to fail. Relief valves are set at approximately 7bar for regulators designed to give an

output of 4bar (Aitkenhead et al, 2007). The pressure and temperature of the cylinder

contents decrease with use. In order to maintain flow, constant adjustment is required

(Aitkenhead et al, 2007). The flow is controlled either by needle valves and flowmeters or

electronically. This is measured in a tapered, transparent plastic or glass tube with a light

weight rotating bobbin or ball with bobbin-stops at either end of the tube to ensure visibility of

the flow of gases. The bobbin is held floating within the tube by the gas flow passing around

it. The higher the flow rate, the higher the bobbin rises within the tube. The reading of the

flowmeter is taken from the top of the bobbin (Al-Shaikh et al 2007). The gas flowmeters are

linked either mechanically or pneumatically to prevent Nitrous Oxide being administered

without Oxygen. This is a safety mechanism called the hypoxic guard. This causes the

Nitrous Oxide flow to decrease if the Oxygen flowmeter is adjusted to give less than 25-30%

Oxygen. In the event of a failure of the Oxygen supply, an alarm will sound and the flow of

Nitrous Oxide is terminated (Nathanson 2007).

Preparation of drugs and equipment

The author checked that the suction was working and suction tubing was long enough to

reach the patient and had a sterile Yankeur sucker tip attached at the end. The size 5 face

mask was prepared for Mr X and attached to the Bain breathing system with a filter, catheter

mount and angle piece. The breathing system was tested to make sure there were no

obstruction and the adjustable pressure valve was left open before use. All monitoring

equipment was ready and at hand (Al-Shaikh et al 2007). The author, under the supervision

of her mentor, aseptically prepared and primed an intravenous infusion of a 1 litre bag of

crystalloid Hartman’s solution by attaching a fluid giving set with an extension and 3 way tap

for administration of intravenous drugs. This was to hydrate and maintain fluid balance in

patients as they are usually starved before surgery. Crystalloids are isotonic solutions with a

similar fluid and electrolyte composition to extracellular fluid (Robinson et al 2012). A tray

was prepared holding a lubricated reinforced size 5 laryngeal mask, a size 2 and 3

oropharyngeal (Guedel) airway and a 20ml syringe to inflate the outer rim of the laryngeal

mask. Reinforced laryngeal masks are used for head and neck surgeries. The tubes have a

stainless steel wire spiral in its wall making it flexible and resistant to crushing and kinking.

This is suitable as the surgeon will be operating very closely to the airway and may obstruct

the tube (Al-Shaikh et al 2007).

The author observed the mentor prepare a tray of emergency anaesthetic drugs.

DRUG TYPE AMOUNT

Ephedrine Increases heart rate and Diluted in Sodium Chloride

myocardial contractility and (9ml NaCl + 1ml of Ephedrine =
peripheral vasoconstrictor drug 10ml) to make 30mg/10ml
Suxamethonium Depolarising muscle relaxant 100mg in 2ml
with rapid onset of less than 1
minute and short duration of
action of 3-5minutes
Atropine Antimuscarinic drug, used to 0.6mgs/1ml
treat slow heart rate
(bradicardia)
(British National Formulary (BNF) 2010)
Patient care in anaesthetic room

The author attended the team briefing with all members of the scrub team, the surgeon and

the anaesthetic team. The brief promoted a coordinated and collaborative approach to cater

the patient’s individual needs. The World Health Organisation (WHO) Surgical Safety

Checklist (2008) was discussed and all aspects covered from the anaesthetic, surgical and

scrub side. With everyone’s agreement, the patient was sent for.

The patient was received into the anaesthetic room and a steady flow of conversation

carried on between the author, the orderly and Mr X. This relaxed the patient as he was

feeling very anxious and he was more at ease to see familiar faces from earlier that morning.

Communication during handover of patient from the ward nurse to the operating department

practitioner was clear and effective. This promotes an interdisciplinary approach and

teamwork. The care plan, anaesthetic chart, prescription chart and consent form was

checked against the patient’s wrist label to ensure that the right patient was there for the

intended procedure. This also reassured the patient that his safety was the utmost priority of

the theatre team. Before any surgical intervention, the patient’s informed consent must be

gained in writing by health professional responsible for the procedure. This is good practice

and also a legal and ethical requirement (Gwinnutt 2008). The patient must fully understand

the intervention, its benefits and possible risks. Failure to secure an informed consent can

lead to the health professional being prosecuted by the patient and subject to disciplinary

action by the regulating body Health and Care Professions Council (2012a). The author

completed The World Health Organisation (WHO) Surgical Safety Checklist (2008) ensuring

all relevant questions were asked and accurately recorded in accordance to The Health Care

and Professions Council (HCPC) (2012). Mr X was asked if he had any loose teeth, caps or

crowns. This was for the purpose of airway management and the possibility of accidently

knocking out the teeth during intubation. He was also asked if he had any jewellery on, any
piercing or any metal work fitted in the body from any previous surgeries as this would affect

the diathermy plate needed to coagulate any bleeding vessels or to cut tissue (Al-Shaikh et

al 2007). He was once again asked when he last ate and drank.

The anaesthetic process

The author worked with the operating department practitioner and attached all the

monitoring, the pulse oximeter, blood pressure cuff and electro cardio graphy dots. The vital

readings recorded as:

Mr X’s Vitals Baseline parameter in Mr X’s parameter in Reason

pre-assessment the anaesthetic room
Heart Rate 55bpm 85bpm The patients was
anxious and nervous
Blood Pressure 160/78mmhg 200/110mmhg The patients was
anxious and nervous
Oxygen Saturation 98% 98%

The anaesthetist inserted a 20 gauge cannula on the dorsal metacarpal vein at the back of

Mr X’s left hand for intravenous access and attached the ready primed Hartmann’s drip on to

it. The author secured it with tegaderm dressing and dated it. Mr X lay in a supine position

for induction of anaesthesia. On the anaesthetist’s instruction, the author pre oxygenated the

patient by holding the mask attached to the breathing system over the patient’s mouth and

nose. Pre-oxygenation was 2-3 minutes to allow a larger reservoir of oxygen and to

denitrogenate the lungs in preparation for hypoxia (Robinson et al 2012). The anaesthetist

intravenously administered 100mg/2ml of Fentanyl, an opioid analgesic for pain relief (British

National Formulary (BNF) 2010). In accordance with the triad of anaesthesia, the

anaesthetist gave Mr X (200mg/20ml + 100mg/10mls) 300mg/30mls of Propofol which

placed him in an unconscious state. Propofol is used as an induction agent but can

sometimes cause hypotension (abnormal low blood pressure) and bradicardia (slow heart

rate) (British National Formulary (BNF) 2010). Mr X was also given Ondansetron 4mg/2ml,

an antiemetic drug used to manage postoperative nausea and vomiting. A 6.6mg/2ml of

Dexamethasone, a corticosteroid drug, was administered as an anti-inflammatory (British

National Formulary (BNF) 2010). 1.2gm of Co-Amoxiclav, an Augmentic drug was prepared

by mixing Amoxicillin 1g as sodium salt + 200mg Clavulanic acid as Potassium salt. This

was also administered intravenously (British National Formulary (BNF) 2010). The patient

showed signs of excitement and erratic breathing as he reached the second stage of the

triad of anaesthesia. The anaesthetist maintained the anaesthesia by using a mixture of

Nitrous Oxide and Sevoflurane a volatile anaesthetic agent leading to surgical anaesthesia,

the third stage of anaesthesia. (Nathanson 2007)

The anaesthetist took the face mask off the patient’s face and took the pre lubricated size 5

reinforced laryngeal mask from the author to intubate. The author assisted by holding the

patient’s lower lip for easy access. The operating department practitioner passed the

breathing circuit to the anaesthetist to attach the filter on to the laryngeal mask tube. The

author gently inflated the cuff on the reinforced laryngeal mask using a sterile 20ml syringe

with 40ml of air until there were no obvious leaks. The anaesthetist ventilated the patient to

make sure there was no obstruction of the airway and the laryngeal mask was sitting in the

right place. The operating department practitioner secured the laryngeal mask with blendam

tape and the author taped Mr X’s eyes with eyegel to protect them during the surgical

procedure (Nathanson 2007). The author handed a damp throat pack to the anaesthetist to

put into the patient’s mouth to avoid any foreign body passing through the larynx. A label for

throat pack was stuck on to the patient’s forehead for the benefit of the surgical team. This

helps with the swab counts when the surgery is complete and avoids any confusion (Wicker,

2010). The anaesthetist sprayed Lidocaine and Phenylephrhrine Topical Solution, a Local

Anaesthetic inside the nose of Mr X to numb the area and reduce bleeding prior to

performing surgery. It was a 2.5ml of solution which contained 5% Lidocaine Hydrochloride

and 0.5% Phenylephrine Hydrochloride (British National Formulary (BNF) 2010).

Once the anaesthetist was satisfied with the airway management, the patient was ready to

be transferred to the operating theatre. All monitors were taken off and the breathing system
detached from the tube. The drip was turned off and the patient was transferred through.

The breathing circuit was reattached and checked for Carbon Dioxide emissions and the drip

was turned back on. All monitoring was reattached and Mr X was positioned with feet

towards the anaesthetic machine and head at the far end for easy access for surgery. The

author placed a side support on either side of the patient’s arm to protect him from any

hazards from the surgical environment. A rubber sausage shaped support was placed under

his heels to protect him from pressure sores whilst in surgery (Al-Shaikh et al 2007). The

operating department practitioner placed a diathermy plate on Mr X’s left thigh and covered

him back with the blanket to keep him warm and to protect his dignity. The World Health

Organisation (WHO) Surgical Safety Checklist (2008) was rechecked and acknowledged by

all members of the team. The scrub team then draped Mr X and commenced surgery. The

anaesthetist maintained the anaesthesia perioperatively by administering a mixture of

Nitrous Oxide and Sevoflurane (Robinson et al 2012).

Conclusion

By exploring, evaluating and reflecting upon the pre-operative and anaesthetic process of Mr

X’s perioperative journey, the author enhanced her personal learning and development. The

knowledge gained from theory of anaesthesia and application of different anaesthetic

techniques reinforced the research from the learning environment and reading material. The

reflection led the author to view the holistic approach to patient care and patient safety

through the best practice followed by the theatre team through effective communication and

collaborative team work.

(3219 words)
References section:

 Aitkenhead A BSc MD FRCA, 2006. Textbook of Anaesthesia, 5e. 5thEdition. Churchill

Livingstone.
 Alexander M, CBE BSc PhD RN RM RNT FRCN, 2004. Nursing Practice: Hospital and Home,
The Adult. 2nd Edition. Churchill Livingstone.
 Al-Shaikh,B. Stacey,S. 2007 Essential of anaesthetic equipment 3rd ed. Churchill Livingstone
Elsevier New York
 BNF 2010. British National Formulary 60 September 2010. 1 Edition. Pharmaceutical Press.

 Cemille O, Ate D, Kemal T, Gamze S, Selmin O. 2007. The evaluation of factors affecting
preoperative fear. [ONLINE] Available at:
http://www.priory.com/anaesthesia/Preoperative_fear.htm. [Accessed 16 April 13].
 Data Protection Act 1998. 2012. Data Protection Act 1998. [ONLINE] Available at:
http://www.legislation.gov.uk/ukpga/1998/29/contents [Accessed 14th April 2013]
 Department of Health, Social Services and Public Safety. 2013. GOOD PRACTICE. [ONLINE]
Available at: http://www.dhsspsni.gov.uk/consent-guidepart1.pdf. [Accessed 29 April 13].
 Gwinnutt C, 2008. Lecture Notes: Clinical Anaesthesia. 3rd Edition. Wiley-Blackwell.
 HCPC - Homepage (Health and Care Professions Council). 2012. HCPC - Homepage (Health
and Care Professions Council). [ONLINE] Available at: http://www.hpc-uk.org [Accessed 14th
April 2013].
 Health and Safety Executive (HSE), 1996. Anaethetic Agents: Controlling Exposure Under
COSHH. Edition. HSE Books.
 Martin E, 2010. Concise Medical Dictionary (Oxford Paperback Reference). 8th Edition.
Oxford University Press, USA.
 Nathanson M, MRCP FRCA, 2007. Churchill's Pocketbook of Anaesthesia, 1e (Churchill
Pocketbooks). 1 Edition. Churchill Livingstone.
 Robinson, N. Hall, G. 2012 How to survive in anaesthesia 4th Ed Blackwell Publishing LTD UK
 Wicker P, 2010. Caring for the Perioperative Patient. 2nd Edition. Wiley-Blackwell.
 World Health Organisation. 2008 WHO Surgical Safety Checklist. [ONLINE] Available at:
http://www.who.int/patientsafety/safesurgery/en/ [Accessed 17 April 13].

 QA4 Surgery Trolley System | Anetic Aid : Medical & Theatre Equipment, Hospital Trolleys,
Surgical Instruments, Operating Tables . 2013. QA4 Surgery Trolley System | Anetic Aid :
Medical & Theatre Equipment, Hospital Trolleys, Surgical Instruments, Operating Tables .
[ONLINE]Available at:
http://www.aneticaid.co.uk/catalog/485633/qa4_surgery_trolley_system [Accessed 30 April
2013].