Describe the anaesthetic induction, maintenance and emergence of Mr Hooper. Provide rationales for your answer
You are working as anaesthetic nurse and note that the first patient on the list is Mr Hooper, 70 years old, who is undergoing a laparoscopic cholecystectomy.
What will be an ideal response?
Answers/rationales:
Sequence Rationale
Induction
Pre-oxygenation Provides a reserve supply of oxygen in the patient's lungs during induction and prior to intubation
Administration of midazolam and narcotic Provides sedation and commences pain management
Administration of propofol Induces anaesthesia
Ventilation with bag/mask and oxygen Manages apnoea caused by propofol and muscle relaxant drug
Administration of long-acting muscle relaxant e.g. rocuronium Facilitates intubation and the surgical procedure; it takes 1–2 minutes to act, hence bag/mask ventilation, which provides airway support
Intubation with ETT Facilitates ventilation for surgical procedure
Inflation of ETT cuff Seals airway and facilitates positive pressure ventilation
ETT secured using tape of anaesthetist's choice Prevents ETT being dislodged and resultant airway compromise
Confirmation of correct location of ETT using stethoscope and monitoring of CO2 Ensures equal inflation of each lung, and that the ETT is not located in the right main bronchus or in the oesophagus
Attachment of ETT to ventilator on anaesthetic machine and delivery of appropriate levels of oxygen, nitrous oxide and volatile agent As the patient is paralysed and unable to breathe unassisted, they must be attached to the mechanical ventilator, and anaesthesia maintained using combination of agents
Maintenance
Delivery of oxygen, nitrous oxide and volatile agent (e.g. sevoflurane) or continuous TIVA Provides continuing anaesthesia
Further muscle relaxant drug may be required Provides continuing muscle relaxation for surgical procedure
Haemodynamic monitoring, including temperature monitoring Provides data on the patient's physiological status alerting the anaesthetic team to potential problems
IV access maintained Provides access to circulation for administration of drugs (e.g. analgesia) and IV fluids, if required
Emergence
Reversal of residual muscle relaxants using neostigmine and atropine Non-depolarising muscle relaxants require reversing, to allow return of spontaneous respiration
Switching off of inhalation agents and administration of 100% oxygen; cessation of TIVA if in use Cessation of inhalation agents assists the patient to emerge from general anaesthesia; delivery of 100% oxygen ‘washes out' residual anaesthetic agents
Suction of oropharynx Removes secretions and prevents aspiration and laryngospasm
Removal of ETT when the patient is breathing spontaneously, responding to verbal commands and is haemodynamically stable Demonstrates successful emergence from general anaesthesia and maintenance of airway with minimal support
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