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RN, Anaesthetics 1 Operating Suite, St Vincent's Hospital
[Abstract] [Introduction] [Pathophysiology] [Pre-op Visit and Plan for Care] [The Perioperative Period] [Postoperative Visit] [Conclusion] [Nursing Care Plan (NCP)] [References]
This case study focuses on a patient undergoing a general anaesthetic with a history of cigarette smoking. Cigarette smoking causes many physiological changes In the body. This increases the risks for the patient undergoing general anaesthesia and of postoperative complications.
The components of cigarette smoke, such as nicotine, tar, acids, alcohol, phenol and hydrocarbons, have significant effects on the cardiovascular, respiratory, immune and gastrointestinal systems. Smoking has also been associated with anxiety and increased gastric acidity.
This paper reflects a first hand experience of an anaesthetic nurse involved in the management of a 27 year old female with a ten year history of cigarette smoking. She was admitted for laparoscopy hysteroscopy, dilation and curettage, cystoscopy and urethral dilation surgery under a general anaesthetic.
Included is an overview of potential nursing problems associated with smoking and a nursing care plan for the perioperative period in which the patients needs are assessed, the nursing action highlighted and the rationale given. The perioperative period is then discussed in detail. A postoperative visit was conducted and this is outlined.
In conclusion the nursing care plan is evaluated and the nurse reflects on her role in educating the patent about the effects of smoking on anaesthesia.
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Smoking is an addiction which causes the deaths of 40-50% of those people who continue to smoke (Nel & Morgan, 1996). This suggests that cigarette smoking causes many physiological changes in the body thus putting the patient at an increased risk when undergoing general anaesthesia and further increased risk of postoperative complications. This case study examines my involvement, as an anaesthetic nurse, in the care of a patient who smoked cigarettes and was undergoing general anaesthesia for surgery. It focuses on the preoperative and immediate postoperative phases when I was directly involved in the patient's perioperative experience. A nursing care plan is outlined and the actual nursing care given discussed, including the preoperative and postoperative visit.
The pathophysiology of the patient who smokes undergoing a general anaesthetic is also considered.
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"...Cigarette smoke contains nicotine, tar, acids, alcohol, phenols and hydrocarbons..." (Drain, 1994: 527) so it is little wonder that many systems of the body are affected.
The cardiovascular system is affected by the nicotine in cigarette smoke which causes an increased heart rate and raised blood pressure and peripheral vascular resistance, consequently this "increases myocardial oxygen demand" (Taylor & Goldhill, 1992:46).
While there is a greater demand for oxygen, the carbon monoxide in cigarette smoke binds with the haemoglobin in the blood to form carboxyhemoglobin which reduces the supply of oxygen to the tissues by up to 15%. This results in a supply demand imbalance (Amoroso, 1996). This imbalance may significantly affect the patient undergoing anaesthesia as this is a time when the oxygen demand in the tissues increases. It should be noted that pulse oximetry, a standard form of perioperative monitoring, may not be totally reliable as it only picks up haemoglobin and oxyhaemoglobin. When carboxyhaemoglobin is present, it is interpreted as oxyhaemoglobin by the pulse oximeter. This means that the pulse oximeter overestimates the patient's oxygen saturation, consequently a decreased oxygen saturation is not detected straightaway (Taylor & Goldhill, 1992).
"Smoking is also a major risk factor for arterial thromboembolism and coronary vasospasm by multiple pathways including direct endothelial damage and haematological, metabolic and biochemical disturbances" (Nel & Morgan, 1996:309). this potentiates the chance for an adverse cardiovascular episode in the perioperative period.
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The respiratory system is widely affected by smoking and this has many implications for anaesthesia. Smoking causes the destruction of cilia, leading to increased mucous secretion in the airways. The trachea, larynx and bronchus are particularly affected -increasing the chance of laryngospasm and bronchospasm on both induction and emergence from anaesthesia (Woerlee, 1988). Small airway narrowing, reduced pulmonary surfactant and compliance mean less oxygen exchange and a tendency for a ventilation-perfusion mismatch (Amoroso, 1996).
Other respiratory events which may cause adverse effects during the induction and emergence of anaesthesia with a patient who smokes are coughing and breath holding (Dennis et al., 1994:451). The effects of these include decreased oxygen saturation and decreased airway clearance. Potential postoperative pulmonary complications include atelectasis and pneumonia which occur more frequently with a patient who smokes and are related to causes of morbidity in these patients (Nel & Morgan, 1996).
The immune system is affected by cigarette smoking such that "...aspects of the immune response including reductions in neutrophil activity, in immunoglobulin concentrations and natural killer cell activity" (Jones et al., 1997: 1) are influenced. This impaired immune response has implications for surgery in that chances of wound infection are increased and wound healing decreased. "Impaired wound healing can also be attributed to the toxins in smoke and the resulting poor oxygen perfusion throughout the body..." (Nel & Morgan, 1996:3 10). The main anaesthetic implication for the patient with a decreased immune response is the increased potential for respiratory tract infections postoperatively (Nimmo & Smith, 1989).
Another physiological change that takes place is the stimulation of hepatic enzymes by smoke which, as a consequence, increases the metabolism of drugs administered. This influences the dosage requirements of drugs to be administered, in particular analgesia requirements may need to be increased (Stoeltinget al., 1988).
Smokers may also be at risk for aspiration of gastric contents due to a delay in gastric emptying and an increase in gastric acidity caused by smoking (Nel & Morgan, 1996). There has also been an association with smoking,. anxiety and increased gastric acidity. Not only does smoking increase gastric acidity but so does anxiety. Of course, when a smoker is anxious, more cigarettes are smoked creating a vicious circle in relation to gastric acidity (Lichtor, 1990). This obviously has implications for anaesthesia where the anaesthetist and anaesthetic nurse must consider the actions that must be taken to stop aspiration from happening, while also considering the aforementioned factors relating to a patient who smokes and its effects on anaesthesia and surgery.
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The patient, a 27 year old female whom I shall name Miss X for confidential purposes, was admitted to hospital the afternoon before her surgery. She was scheduled for a laparoscopy, hysteroscopy, dilation and curettage, cystoscopy and urethral dilation.
Miss X is a legal secretary who is studying floristery at college and lives with her partner of five years. She has smoked 20 cigarettes a day for the last 10 years and consumes a glass of wine a day. Her presenting problems involve hypermenorrhea included increased clotting, urine frequency with desperate urges to void and poor stream.
When I spoke to Miss X she appeared quite anxious, this was evidenced by her worried facial expressions and tone of voice. Miss X discussed with me the possibility of her wanting to get pregnant soon and said she was worried that these problems may indicate some abnormality thus preventing her from falling pregnant. Her only medication was the oral contraceptive pill and she stated that she was allergic to dairy products. This was to be the first time she had ever experienced anaesthesia and surgery.
During the interview I informed her about theatre routine in an attempt to decrease her anxiety levels which were quite apparent in her many questions about the operating theatre experience. I also informed her about smoking's effect on anaesthesia and encouraged her not to smoke for at least 12 hours before surgery so as to minimise any complications.
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Upon her arrival at the theatre reception, I greeted Miss X and checked her into the suite using a routine checklist. When she arrived in the anaesthetic bay, 1 orientated Miss X to her surroundings and again gave her a brief explanation of the anaesthetic procedure.
I commenced monitoring her vital signs with use of a 3 lead ECG, a blood pressure cuff on her arm and a pulse oxygen saturation monitor placed on her finger. I noted her baseline observations were normal, blood pressure 125/8OmmHg, pulse 80/minute; however her oxygen saturation was only 96%. Possibly her cigarette smoking was the cause, as she didn't have any kind of narcotic pre-medication which may have reduced her saturation. As discussed previously, it must also be considered that her saturation level of 96% may be even lower due to the presence of carboxyhaemoglobin in her blood. I commenced oxygen 6L/min via a Hudson mask explaining to her that before an anaesthetic it is optimal to have the lungs filled with as much oxygen as possible and that we must consider that her saturation level of 96% may be even lower due to the presence of carboxyhaemoglobin in her blood.
After checking Miss X's allergies again, 1 administered approximately 2 nil of Procaine (local anaesthetic) just lateral to her vein before inserting a cannula while also explaining this to her. Once the cannula was in the vein, I commenced 1000 ml of Hartmanns (as per medical orders) via a pump giving set. As she had fasted since midnight, the drip rate was set at a steady rate for rehydration.
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While waiting for the anaesthetist, I maintained her comfort by providing a warm blanket and conversing with her in a friendly manner so as to dispel some of her anxiety. She mentioned to me at this stage that she hadn't smoked for twelve hours.
As a prelude to the anaesthetic, the anaesthetist administered 3 mg of Midazolam (an amnesic/sedative) so as to decrease her anxiety which subsequently left Ass X in a light doze and much less anxious (Drain, 1994). Observations of her airway and vital signs were maintained at all times.
Upon induction, Ass X's supply of oxygen was changed to a black mask connected to a Bains circuit. The induction agent used was Propofol with Procaine added (the Procaine was used to decrease the sting felt in the vein as the Propofol was administered). Propofol was the induction agent of choice as it acts synergistically with Midazolam and has little central nervous system effects on the patient along with having antiemetic properties (Drain, 1994).
Although very drowsy, Ass X was informed by the anaesthetist that she was "going to go off to sleep now". The muscle relaxant used was a non-depolarising agent called Ataracurium (Drain, 1994). Manual ventilation was begun by the anaesthetist. Vital signs continued to be stable along with an increased saturation from baseline to. 98%. Nitrous Oxide (an analgesic gas) and Isoflurane (a volatile agent) were used to maintain anaesthesia.
Miss X was intubated after 3-4 minutes of ventilation to achieve optimal oxygenation and allow time for the muscle relaxant to take full effect. A standard endotracheal tube of size 7.5mm was used and passed through the vocal cords without any difficulty. The endotracheal tube cuff was inflated with only enough air so that no leak was heard on ventilation. The tube was then tied and eyes taped so that no corneal irritation would occur. Fortunately, throughout this time no coughing or laryngospasm was experienced by the patient, and vital signs remained stable.
Miss X was transferred to the operating room and placed onto the operating table in a lithotomy position while monitoring was reconnected. Intravenous (IV) fluids continued to be administered throughout the surgical procedure. The surgical procedure consisted of a laparoscopy, hysteroscopy, dilation and curettage, cystoscopy and urethral dilation which took approximately one hour to perform. No abnormalities were found.
Miss X was ventilated using mechanical ventilation and the anaesthetic continued with the use of oxygen, nitrous oxide, Isoflurane and an Ataracurium infusion. Once the surgery was finished the Atarcurium infusion and the volatile agents were turned off. Neostigmine (a muscle relaxant reversal agent ) was administered in conjunction with Glycopytrelate which combats the bradycardic effects of Neostigmine and provides for a smoother reversal (Drain,1994). The eye tape was removed.
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Once Miss X was conscious and breathing independently and her vital signs stable, a Yankeur sucker was used to clear the copious amount of secretions in the airway before extubation. The endotracheal tube cuff was deflated and Miss X was asked to take a big breath in and upon exhalation the tube was removed. More suction was used to clear the airway before oxygen was delivered by a black mask so as to increase oxygenation before transport to recovery.
When transporting Miss X to recovery, jaw tilt was maintained by the anaesthetist so as to provide a patent airway. Upon arrival in recovery, Ass X was administered oxygen at rate of 8L/min of oxygen and vital signs were recorded at 15 minute intervals. Vital signs remained stable and Miss X's airway was observed for any signs of laryngospasm/bronchospasm.
Her IV fluids continued and when they were finished, her cannula was capped as the anaesthetist had ordered. Her 2 small surgical incisions in her umbilicus and hypogastric region were observed for any bleeding or swelling and her comfort was maintained initially by warm blankets.
Though fully conscious Ass X was disorientated to time and place. This was evidenced in her comment immediately on waking up when she said, "Can I have a cigarette?", ironically while coughing a great deal. This made me realise that she would probably continue smoking after recovering from this operation.
I orientated her to time and place and asked if she felt nauseous or if she had any pain. Miss X said she did feel some pain around the surgical sites and asked for some pain relief, which I promptly gave her as per the anaesthetist's orders. By this stage she was wide awake and had been in the recovery room for half an hour so the administration of Panadeine Forte x 2 seemed appropriate as she was to be discharged from the ward that evening.
I informed her about her incision sites and that to prevent infection, she should try and keep them clean. She had a peripad in situ with net pants on to hold it in place. I explained to her that she may have some bloody drainage from her vagina and urethra as a result of the surgery but that the drainage should cease in a couple of days so that she should not be alarmed. When discharged from recovery, her vital signs were stable, saturation on room air was 97%, she was oriented, pain free, comfortable and informed about her surgery.
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I visited Miss X just before she was due to go home, 4 hours after leaving recovery. She discussed with me how although her perioperative experience had been frightening, by going to see her prior to the operation, 1 had helped to decrease her anxiety and that when she arrived at the theatre reception, it was good to see a familiar face which made her feel more at ease.
Miss X didn't remember much about the anaesthetic experience due to the Midazolam administered, however she did remember waking up in recovery coughing and having, as she put it, a "froggy throat".
She said her pain around the surgical sites had settled and that she looking forward to going home to rest. Miss X also commented on how she was able to refrain from cigarette smoking for the 12 hours prior to the operation, as I had encouraged, however was now really craving for a cigarette. I explained to her that it was a good recovery from the anaesthetic because she had refrained from cigarette smoking and that if she wanted to reduce her chances of a respiratory tract infection or of a wound infection, she should still refrain from smoking; however I'm not entirely sure she took heed of my words. She thanked me for the time I had spent with her and said I had made her experience in the operating theatre a better one than she had expected.
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I believe that Miss X's smooth, uncomplicated recovery was contributed to by her refraining from cigarette smoking 12 hours prior to her anaesthetic, advice which I'm glad to have been a part of, that is, by making her aware about the effects of smoking on anaesthesia.
Her attitude upon being discharged, however, was that of "Oh well, I've come through all right, so I'll go home and have a cigarette", which is a shame, as there is only so much education and encouragement you can give a patient. The decision to stop smoking is ultimately up to the patient. Nevertheless, I would like to think I have been a beneficial part of Miss X's total operative experience.
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Amoroso, P. (1996). Smoking and Anaesthesia, in Goldstone, J. C. and Pollard, B. J. (Ed.). Handbook of Clinical Anaesthesia. Churchill-Livingstone: New York.
Dennis, A., Curran, J., Sheriff, J. & Kinnear, W. (1994) Effects of passive and active smoking on induction of anaesthesia, British Journal of Anaesthesia, 73:450-452.
Drain, C. B. (1994) The Post Anaesthesia Care Unit W. B. Saunders Company: Philadelphia
Jones, R. M., Rosen, M. & Seymour, L (1987) Editorial Smoking and Anaesthesia, Anaesthesia, 42:1-2.
Lichtor, R. (1990). Psychological Preparation and Preoperative Medication, in Miller, R. D. (Ed.). Anaesthesia (3rd ed) Churchill-Livingstone: New York
Nel, M. R. and Morgan, M. (1996) Editorial Smoking and Anaesthesia Revisited, Anaesthesia, 51:309-311.
Nimmo, W. S. and Smith, G. (1989) Anaesthesia Volume One. Blackwell Scientific Publications: Carlton.
Stoelting, R. K, Dierdorf, S. F. & McCammon, R. L (1988) Anaesthesia and Co-existing Disease. (2nd edition) Churchill-Livingstone: New York
Taylor, T. H. and Goldhill, D. R. (1992) Standards of Care in Anaesthesia. Butterworth Heinemann Ltd: Oxford
Woerlee, G. M. (1988) Common Perioperative Problems and the Anaesthetist, Kluwer Academic Publishers: Dordrecht
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