Post-Operative Chapters 19 and 20

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: Vasanthi.vidyasagaran@gmail.com

POST-OPERATIVE – Chapter 20

Post Procedure Haemorrhage – Can Alternative Medicine Be a Cause

A 35-year-old woman with a two days history of missed abortion was posted for evacuation of the uterus. She was taken up under TIVA with Propofol 100 mg, Ketamine 50 mg and supplemental oxygen. The procedure was over in 10 minutes and was uneventful.

There was a call from the recovery area after half an hour that the patient was bleeding profusely and was in shock. Blood was sent for investigations, and in the mean time she was taken up for examination and exploration. She was intubated with Midazolam 2mg and Fentanyl 50 microgram. and Injection Atracurium 25 mg.

The source of the bleed was identified to be from within the uterus itself, no injuries were found. Ultrasound abdomen did not reveal any collection or perforation. She was not clotting. Laboratory reports revealed a low platelet count of 30,000. Four units of packed red blood cells and four units of platelets were transfused. Vital signs stabilised over an hour and she was shifted to the ICU for monitoring. She was extubated after 3 hours. The cause of the low platelet count was intriguing. On probing further, she revealed history of taking some herbal medications for more than 15 years for sinusitis, the details of which were not available.

Discussion

The American Society of Anaesthesiologists on its website, recommends patients to bring all substances with prescription or over-the-counter when they meet the anaesthesiologist before surgery or on the day of surgery. Awareness has to be created among surgeons, anaesthesiologists and general public regarding the possible interactions with anaesthetic agents and complications during surgery.

There are other drugs resembling steroids as well as those containing heavy metals like lead. Hematopoietic system, cardiac and liver evaluation will be helpful preoperatively in those taking long term alternative medication. Even if patients do not reveal their medication history, probing questions should be asked especially in those receiving treatment for arthritis, infertility, asthma, and sinusitis, and even diabetes.

References

Adrian Wong, Stephen A Townley, Herbal medicines and anaesthesia Contin Educ Anaesth Crit Care Pain (2011) 11 (1): 14-17.
American Society of What you should know about herbal and dietary supplement use and anaesthesia. 2003. Patient Information Leaflet.
Hodges PJ, Kam The peri-operative implications of herbal medicines. Anaesthesia 2002; 57:889-899.
Sukhminder Jit Singh Bajwa and Aparajita Panda Alternative medicine and anaesthesia: Implications and considerations in daily practice 2012 Oct-Dec; 33(4): 475–480.

POST-OPERATIVE – Chapter 20

Preterm Infant and Postoperative Apnoea

Case 1

A 5-day old baby, born at 31 weeks gestational age, weighing 1.8 kilograms was posted for emergency needle aspiration and/or incision and drainage of septic arthritis of the hip. No other congenital abnormalities were present. An IV line was started on the left dorsum of hand. Injection Atropine 20 µg/kg, followed by 2 mg of diluted Ketamine were administered. A face mask with O₂/N₂O 50:50 was held to maintain the airway. The procedure was completed within 5 minutes. Saturation was maintained at 100% and respiration was regular. Pulse rate was 150 beats/min.

Child was shifted to the recovery room with instructions to the mother and the nurse to watch for respiration. Within 10 minutes, we were called into recovery as the child was not breathing. Baby was immediately ventilated and intubated. Though respiration and heart beat were established after resuscitation, he did not regain consciousness. Brief period of apnoea causing hypoxia was enough to cause catastrophe. The child had to be on ventilatory support and had a prolonged stay in NICU, before recovery. Hence early identification of apnoea, and immediate intervention is vital, especially in pre- term babies.

Case 2

15 days old, 30 weeks born preterm baby, weighing 1.5 kilograms was posted for incision and drainage of a thigh abscess. General anaesthesia was started with Injection Atropine 20 µg/kg, and Injection Ketamine 2 mg. Sevoflurane was given along with Oxygen and Nitrous Oxide with a paediatric circuit. The procedure lasted for 15 minutes. After ensuring spontaneous regular respiration, SpO2 of 100% and a pulse rate of 133 beats/min, the baby was shifted to the recovery.

In about ten minutes we received an emergency call from the recovery. On arrival, baby was floppy. Oxygen was being provided by nasal cannula, but baby was not breathing. The monitor showed bradycardia at 50 beats/min, and saturation 72%. On examination, respiration was absent and pulse could not be felt. A dose of Atropine was given and the bag mass ventilation was done with 100% oxygen. After one cycle of cardiac compressions and bag mask ventilation, child was revived. Child was kept under apnoea monitor for further 24 hours before discharge. Mother was taught about potential problems and how to watch for breathing. The nurse was attending to some other child and as the oxygen was anyway flowing did not notice that the child was not breathing.

Discussion

All systems are under developed in a preterm infant.

It is well documented that preterm babies are susceptible to apnoeic episodes, particularly post anaesthesia. Decreased ventilatory control, and hypo responsiveness to hypoxia and hypercarbia is one of the prime reasons for post-operative apnoea in pre-term infants. Despite adequate precautions, critical events may happen. Hence it becomes mandatory to monitor them very closely not only in immediate postoperative period, but for 24 to 72 hours, after surgery.

These two case scenarios highlight that in addition to the floor nurse, presence of the parent with the baby will ensure close monitoring in recovery and early recognition of slowing of respiratory rate. The nurse had been complacent that oxygen was on flow but failed to recognize apnoea. The parent must be educated to be vigilant and watch for any change in respiration.

Issues of logistics come into importance here. The nurse-baby ratio is not always 1:1, hence close apnoea monitoring is not 100% feasible, especially when there is more than one baby to attend to. While it is important to maintain a 1:1 ratio, allowing a parent to stay by the bedside of the baby in recovery is helpful in these scenarios for early recognition. Apnoea monitors like in NICU must be available in infant postoperative wards for early warning.

Anaesthetists are often called to care for such babies outside of the operating theatre, such as scan centres. This group of babies, in addition to having the routine risk factors of paediatric population (vulnerability to drugs, sedation and hypoxia), have problems of preterm immaturity, cardiorespiratory defects, biochemical abnormalities affecting drug metabolism, and other associated syndromes. Hence it is essential to have proper equipment, like MRI compatible monitors, oxygen supply, airway equipment, emergency drugs and adequate personnel trained to provide care.

Post anaesthesia recovery area must be available in hospitals, even for minor procedures. However short the procedure may be, preparation and recovery standards must be of universal grade.

References

S Walther-Larsen et al, The former preterm infant and risk of postoperative apnoea: recommendations for Acta Anaestehsiologica Scandinavica 2006;50:888-893
Welborn, “Perioperative Management of the Former Preterm Infant” in Pediatric Anesthesia Handbook, Terrance A. Yemen, editor. New York: McGraw Hill (2002). pp. 130-142
Cote CJ et al, Postoperative apnoea in former preterm infants after inguinal A combined analysis. Anesthesiology 82:809, 1995
Kawshala Peiris, David The prematurely born infant and anaesthesia Continuing Education in Anaesthesia, Critical Care & Pain. Vol 9 No. 3, 2009.

Post-Operative Chapters 19 and 20