Assessment 5. Case analysis Essay Example

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The Name of the School (University)

The City and State where it is located

Clinical Presentation

The most significant aspects of clinical presentation relevant in this case are the instance of CIPD, hypertension, nervous dysfunction and GORD. These illnesses that have afflicted the patient over the course of the last few years are the likely cause of his current complications. They have some overlapping symptoms and some that are quite different. In going into anesthesia, it is important to take into consideration their clinical presentation to avoid complications.

The patient is most concerned and anxious about the exacerbation of CIPD symptoms that have resulted in many complications in the past. The patient was involved in a Micro – Spinal nerve decompression L4/5 in 1995 that is a result of serious demyelinating inflammatory polyradiculoneuropathy that has likely progressed in the preceding years. While complete recovery is possible, about a third of the patients will relapse. Nevertheless the patient being older, they are more unlikely to have relapsed as the majority of relapse patients are of a younger age. However the onset of CIPD is quite insidious and hence its documentation is often difficult. Critical to note is that post his operation he underwent a Panendoscy-Watermelon stomach surgery in 2012 and an R/O nasal polyps procedure in 2003. This shows that his CIPD has been in a state of relapse since 1995 as respiratory and gastrointestinal infections have been reported in patients suffering from CIPD. He has had several Carpel Tunnel release procedures which may also have had impacted his muscle strength resulting in limb weakness. It is important to ask the patient if they have limb weakness including the distal and proximal muscle weakness. If the client presents with numbness or tingling sensations in either the hands or the feet, this could be a symptom of CIPD relapse or progression. While only small proportion of patients experience acute symptoms, which progress steadily it is critical to determine if this patient is one of those patients. As a patient that was once treated for CIPD the decision of relapse will be made depending on the length on which the patient has experienced his symptoms. In most instances, autonomic system dysfunction is usually a greater indicator of CIPD. The patient has had cardiac problems in hypertension, high cholesterol having been diagnosed with Hypercholesterolemia, hemorrhoids, bowel and bladder dysfunction, and nervous system failure.

The clinical presentation of the patient is critical in determining the type of medicines that would be appropriate for the anesthetic procedure that he will undertake. Having arrange of complications mainly from his affliction from CIPD makes this a very complicated procedure. The patient presents with many symptoms that may likely be exacerbated after the anesthetic procedure. The fact that the patient is anxious about exacerbating his symptoms is a bad thing for the procedure. Having nervous and cardiac complications it is likely that having this surgery may exacerbate these conditions and possibly others. The patient has had GORD for over 10 years and this will probably make his symptoms worse given his history of Partial Glossectomy and Radical Neck Dissection for Squamous Cell Carcinoma. This patient will need utmost care to make the surgery a success.

Preoperative Assessment

The importance of preoperative assessment is that it allows for high quality and secure practice. It involves gathering the patient’s information, diagnosis and identifying and managing safety issues as per the needs of the patient. By looking through the patient’s standard info, the risks linked to the patient are easily identified. In Mill’s case, his record of past hypertension, CIDP among others can help the physicians come up with a plan fit for him. Preoperative assessment helps to see if the patient may require further assessment than that which is given by a nurse. This may involve tests such as cardiopulmonary exercise test and have the opportunity to make known to the patient the risk they face while undertaking the surgery. The assessment allows physicians choose the appropriate postoperative care that the patient needs.

By reviewing the results from the nurse, the clinic can provide support and training for the patients with high risk. The number of the staff required in the operating room can be determined also in this stage depending on the risk of the patient. Mr. Mill’s case requires a lot of attention. Having gone through previous surgery and considering his age, a series of tests need to be conducted. Considering the high risks he pauses, plans are necessary to how the procedure will be done and how to prepare for any risks such as respiratory failure during the surgery (Jones, Swart & Torbay, 2014).

One of the most critical aspects of preoperative aspects that will have to be taken into consideration is the medications, which the patient is on or has used in the past. Different medications will have different reactions if combined with others. Some medications may possibly result in complications if combined with anesthesia medications. Allergies of the patient will also need to be taken into account in this regard. The patient is allergic to Metoprolol that may be used for the treatment of hypertension and chest pain that Mr. Mill suffers from. He is similarly allergic to codeine an opioid anesthetic that may be used in anesthesia and may cause the patient to have an anaphylactic shock. The patient must stop the usage of Caduet that may possibly cause irregular heartbeat and pulse and may be fatal during anesthesia.

Impact of Co-morbidities

A recent research carried out on the relationship between intra-abdominal pressure and obesity related co-morbidities. The study showed that the intra-abdominal pressure was elevated in the morbidly obese patients. This was linked to the hypertension. These patients present a challenge to anesthetists. This challenges can be technical or psychological changes. The significance of preoperative care is highly appreciated where co-morbidities are brought to light. Due to obstructive sleep apnoea, there is need for intensive care postoperative (collighan & Bellamy, 2009).

In hypertensive patients, concern on whether doctors need to consider postponement of the surgery is often seen to arise. The question on what anaesthetic risk is paused by treating the hypertension. It has been noted that where the hypertension is moderate, say 180/120 mmHg, then the patient is not at risk and surgery should not be postponed. Is the hypertension is severe, the benefits are of considering a delay to treat the hypertension should be weighed against the risk the patient is subjected to if the surgery is not carried out immediately. Arrhythmia has been reported to develop more highly during anaesthesia where the patient’s hypertension is not treated. Arterial pressure is observed to in both patients with severe and mild hypertension (James, Dyer & Ryan, 2011).

The most significant of comorbidities affecting Mr. Mill is the instance of CIPD, GORD, and hypertension. Having CIP and hypertension means that there is a probability that the medications that are used to cure one illness may negatively affect the treatment of the other. During anesthesia, there will be a need to manage his hypertension, and CIPD. While some medications may be useful to reduce potential hypertensive complications, such medications may exacerbate the instance of GORD complications. The patient is afflicted by hypertension and has undergone procedures to treat this. Clearly, this makes the patient more vulnerable to CIPD complications. The operating doctor will need to remove the patient from all medications particularly hypertension medicines which may result in anaphylactic shock for the patient during anesthesia.

Planning for Anesthesia

Planning for anesthesia is important. The patient’s needs to be prepared for the anesthesia and to also be made aware of the anesthesia technique that has been picked for them. This information also helps to calm the patients and to also inform them of the postoperative care options that come with the technique. Moreover, it becomes important for the physician to guide the patient in coming up with a decision that allows them decide which aesthesia to use. It also helps to prevent malpractice litigations (Jerome & Michael, 1996). Where elderly people are the patients, the team of physicians, surgeons and anesthetists need to be involved. This is because of the operational risk that they possess. Keen attention needs to be paid to the postoperative delirium.

Once the patient is fully aware of what the risks and benefits of using the anesthesia are, then they can sign the consent form. The anesthesia technique can be explained to the patient to help them be psychologically prepared. The patient can be guided on the preoperative fasting. The pain relief method, any possible risks and expected sequelae should be addressed. Any preoperative prescriptions should be made that should also include carbohydrate drinks. Team conducting the procedure should discuss the details presented in the anesthetic record (Jones, Swart & Torbay, 2014).

It is not only important that the patient is made aware of the risks and benefits of using anesthesia. It is also important that Mr. Mill accepts and acknowledges these risks and benefits before undergoing the surgery. Pre-operation the patient needs to know the entire team that will be operating on him. It is critical that persons such as anesthetist and nurses talk to the patient to ensure that they have all the information regarding his allergies before the anesthetic is administered. The patient has asserted his anxieties about his CIPD complications being exacerbated by the procedure and hence there needs to be procedures put in place to deal with this. The patient would have to be counseled on how to deal with the symptoms and complications which will arise from the procedure.

Post Operation

Post operation, patients are often presented with different symptoms among them nausea, vomiting, sleep disturbance and so forth. These symptoms to an extend lead to the patient’s extended stay in the hospital. There is need to address these postoperative symptoms mainly because, the symptoms if not addressed would lead to a long term situation. For example, the pain being experienced can result to chronic pain syndrome. Analgesic agents have been linked with the success story of pain reduction. Reduction in pain is often linked with the success of the postoperative care, hence, analgesic agents can come in handy for this process (Davies, Graham & Myles, 2006).

These analgesic agents for example i.v patient controlled analgesia (PCA) using opioids and regional analgesia can present side effects during their administration therefore there is need to control this. It is said that combing local peripheral and central nerve blocking anesthesia with the PCA i.v opioid is the whole idea behind the analgesic technique. Research concluded in 2003 that combined the views and experiences of different anesthetists suggested that when epidural analgesia was combined with opioids or the cyclooxygenase-2 inhibitors, its efficiency was improved (Adams & Murphy, 2008).

It was seen that, the adverse side effects of epidural analgesia that included nausea, vomiting and the rest were reduced. Furthermore, when the non-opioid agent was added to i.v morphine, it was noted that less morphine was needed to reduce the pain. Another significant result noted from research was that pulmonary complications were highly reduced in patients who undergone abdominal surgery by using the regional anesthesia alongside analgesia. This techniques has no consequence on patients who need spinal anesthesia. It is moreover evident that with older age, these patients are said to be in need of the anesthesia (Bonnet & Marret, 2005).

Reversal of Anesthesia

One of the ways to reverse local anesthesia according to some investigations is the use of lipid emulsion infusion. Even though there is no clear understanding on the mechanism, it was clear that the cardiac bupivacaine concentrations were seen to decrease when the lipid was infused (Litz, Roessel, Thomas &Heller, 2008). Morbidly obese patients present a challenge. Seeing as the patient is at risk of cardiorespiratory impairment, they may need high inspired oxygen fractions, respiratory support and intubation. Elderly patients who undergo orthopedic surgery are said to experience postoperative neurological impairment. The concern is said to point to the patient’s delayed functional recovery, need for more hospital care and increased morbidity. It is therefore important that anesthesia and analgesia be used to help reduce these effects (Chen, Zhao, Paul & Tang, 2001).

In the postoperative care, there is need for the airway patency, oxygen saturation and respiratory rates to be checked periodically. Hypoxemia (Category A2-B evidence) can be detected from monitoring the patient’s respiratory function. It is also important the patient’s blood pressure and pulse be monitored. The level of pain is in, their mental state and their body temperatures should be checked. The hydration state of the patient should be managed, if the patient has lost blood or other fluids, a plan to manage this should be considered. By observing if the patient is still experiencing nausea and vomiting after surgery can help detect any complication and the response needed to reduce adverse effects (Anesthesiology 2013).


Mr. Mill’s condition will have a significant impact on the administration of the anesthetic procedure and hence procedures have to be put in place to ensure that the patient does not suffer debilitating and potentially fatal complications. The fact that the patient has comorbidities coupled with complications and allergies makes the administration of anesthetic an even greater risk for complications. Nevertheless, with proper taking of the patient’s history, the procedure can be done without any negative consequences. How the patient presents is one of the most important aspects before the process of administration of anesthetic is carried out. The medical practitioners must be skilled in determining the clinical presentation of the patient and determine if it is safe to administer anesthetic. The impact of the comorbidities including the medications, complications, and allergies of the patient will need to be recorded in the preparation of the correct medications to be administered. The team must ensure that all medications given do not exacerbate prevailing conditions or result in complications from reactions with current medications. This would need proper planning both in the pre and post stages of operation to enhance the medical outcomes of the patient.


James M. Dayer R. & Rayner B, 2011, A modern look at hypertension and anaesthesia, South Afr J Anaesth Analg, 17(2):168-173.

Bonnet F. & Marret E., 2004, Influence of anaesthetic and analgesic techniques on outcome after surgery, British Journal of Anaesthesia 95 (1): 52–8

Davies R., Myles P. and Graham M., 2006, A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. British Journal of Anaesthesia, 96 (4): 418–26

Adams P & Murphy, 2008, obesity in anaesthesia and intensive care, British Journal of Anaesthesia, 85 (1): 91-108

Anesthesiology, 2013, Practice Guidelines for Postanesthetic Care, American Society of Anaesthesia, 118 (2)

Jerome M. and Michael F., 1996, Current Understanding of Patients’ Attitudes Toward and Preparation for Anesthesia: A Review, International Anesthesia Research Society, 83 (13): 14-21

Jones K., Swart M. & Key W., 2014, Anaesthesia services for pre-operative assessment and preparation 2014, The Royal College of Anaesthetists 

Chen X., Zhao M., Paul F.& Tang J., 2001, the recovery of Cognitive function after general anaesthesia in elderly patients: A comparison of Desflurane and Sevoflurane, Anaesthesia and Analgesia, 93 (6): 1489-1494.

Collighan N. & Bellamy M.,2001, Current anaesthesia and critical care. 12(5): 261-266

Litz R., Roessel T, Heller A. & Stehr S., 2008, reversal of central nervous system and cardiac toxicity after local anaesthetic intoxication by lipid emulsion injection, Anaesthesia and Analgesia, 106 (5) : 1575-1577