Topic: NSG 430: Critical Care Nursing

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Question

Details: Please respond to my peer discussion post based on the posted scenario and used the textbook as my reference please (textbook: Introduction to Critical Care Nursing E-book 9th edition by Mary Lou Sole)

Pre/Post-Op Care Discussion Forum

Read the following patient report, and discuss the questions:

Patient C is a high school senior. During the opening drive in the Friday night football game, Patient C is hit from behind. When he falls, he sustains open, comminuted fractures of his left tibia and fibula. Because he is unable to stand, an ambulance is brought onto the field to transport the young player to the hospital for evaluation.

Upon arrival at the emergency department, Patient C’s leg is examined, x-rayed, and evaluated by the orthopedic surgeon on call. It is determined that prompt stabilization and cleansing of the wound would be optimal for the best possible outcome; thus, Patient C is prepared for surgery. His parents, who were at the game, arrive in the emergency department just moments after the ambulance and are available to give permission for the operative procedure. As Patient C has been medicated for pain, a history is obtained from the parents. There are no notable problems; Patient C is a healthy young man in excellent physical condition. He has not had previous operations and no previous exposure to anesthesia.

Patient C is transferred to the operating room. The anesthesiologist gives the patient a number of preoperative medications, including those to prevent PONV. The anesthesia of choice is enflurane (Ethrane), a volatile gas. The patient first receives succinylcholine prior to intubation, followed by the anesthetic gas. Within minutes, the anesthesiologist notes that Patient C’s carbon dioxide levels are beginning to rise. Just as the surgeon is to begin, the patient sustains a cardiac arrest.

The anesthesiologist immediately stops the insufflation of the gas and begins to administer 100% oxygen. A code response is initiated by the remaining members of the operating team. The rescuer performing chest compressions notes that the patient’s skin is warm. While resuscitative efforts continue, blood for laboratory evaluation is obtained. The arterial blood gas results demonstrate a pH of 6.9, partial pressure of oxygen (PaO2) of 110 mm Hg, and partial pressure of carbon dioxide (PaCO2) of 55 mm Hg. At this point, the anesthesiologist’s suspicions are confirmed; the patient is experiencing an episode of malignant hyperthermia.

As soon as the diagnosis is confirmed, the staff is ordered to administer dantrolene at a dose of 2 mg/kg. The operating room personnel contacts the PACU to ask for assistance in drawing up and preparing the dantrolene. Only one nurse is available to leave the PACU, and she assists with mixing and administering the dantrolene as soon as it is prepared. Additionally, the patient requires repeat doses of sodium bicarbonate to combat the falling serum pH.

Within 15 minutes of administering the dantrolene, the patient begins to demonstrate a perfusing rhythm, although this is punctuated by frequent runs of premature ventricular contractions. Antiarrhythmics are administered to control cardiac complications.

Simultaneously, the patient is cooled with external cold packs applied to the groin and axilla areas. The leg wound is dressed to prevent further contamination during the resuscitative efforts. Repeat blood is obtained for laboratory analysis. The patient’s potassium is elevated, and the patient is started on a glucose-insulin drip.

After the patient’s cardiac condition is stabilized, the operating room staff request transfer of the patient to the PACU for further management. The patient is moved, and the PACU staff becomes responsible for managing the patient. The antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued. During the first 30 minutes in the PACU, the patient’s urine is noted to be deep red color, indicative of developing rhabdomyolysis and potential renal failure. The patient is given 100 mg furosemide, and fluids are increased to 150 mL/hour. Within 20 minutes, the urine lightens in color, although it retains a reddish tinge.

Approximately three hours after the first cardiac arrest, the patient suffers a second arrest with the development of ventricular fibrillation. A second code response is called, and the patient is again resuscitated with dantrolene, antiarrhythmics, and sodium bicarbonate. Once again, the patient responds to treatment and regains a perfusing cardiac rhythm.

The patient is ordered to receive dantrolene every 4 hours for the following 48 hours to ensure that another episode of malignant hyperthermia does not develop. The patient is subsequently stabilized and transferred to the ICU, where he remains for 72 hours.

This my peer discussion post that needs my response.

1. What went well? Could anything have been improved?

Pre-surgery- The patient was assessed quickly during his admittance to the Emergency Department. According to the vignette he received x-rays and was seen by the on-call orthopedic surgeon. The parent’s arrived swiftly and were interviewed to collect the patient’s health history.

During surgery- The anesthesiologist was vigilant and was quick to react by stopping the gas and administering oxygen when a patient went into cardiac arrest. Other team members participated in resuscitation methods and blood was taken from the patient. The lab results showed the patient was experiencing malignant hyperthermia (MH). According to Normandin and Benotti (2018), she defines, “MH is an inherited, pharmacogenetic skeletal muscle syndrome that appears after an exposure to a trigger presenting as a hypermetabolic reaction.”(Normandin, & Benotti, 2018, p.1). The team efficiently obtained medications to begin to stabilize him and they were employing measures to cool off the body

Post Surgery- He was medically managed with antiarrhythmics, glucose-insulin drip, dantrolene and sodium bicarbonate, and furosemide. The patient’s in and outs were monitored as well as labs were repeated frequently. The patient did have another cardiac arrest he continued with medication management to maintain stabilization.

2. Who do you suspect the patient developed MH?

As noted before MH is inherited, one parent can be a carrier for the child to inherit MH. Due to the fact he had no previous surgeries the parents would not have been aware of this trait. It is also possible that when collecting the patient’s history there were no questions about the parent’s reaction to anesthesia. Norman and Benotti identify some things that may have also contributed to this event one being intense exercise and the patient having a feeling warm. (Normandin, & Benotti, 2018) Prior to this event, the patient was involved in a sport that has a high physical demand. The scenario does not report the temperature the game was being played in to determine external factors on body temperature.

3. Do you think that the patient’s fracture was stabilized and repaired? What will need to happen during subsequent surgical procedures for this patient?

While the patient is in the ICU the wound care would be managed by a wound care specialist to decrease the potential for infection. There are some options for stabilization of the fracture in the ICU. One is traction using weights, however, due to the patient’s age the one most likes to be used would be external fixators. According to Lahoti and Arya (2018), this form of stabilization offers the most benefits. It can be set up quickly, allows for quick access to wounds, reduces pain, and is mobile in case the patient needed to be moved (Lahoti & Arya, 2018).

For the patient to receive subsequent surgeries it will need to be well documented the anesthesia used and the intense reaction. The patient will also need to be educated about the trait he has not only to avoid this from happening to himself. He also will have to inform his future spouse and health providers of his future children.

References

Lahoti, O., & Arya, A. (2018). Management of Orthopaedic Injuries in Multiply Injured Child. Indian Journal of Orthopaedics, 52(5), 454–461.

Normandin, P. A., & Benotti, S. A. (2019). New October 2018 malignant hyperthermia guidelines: Is your emergency department prepared? Journal of Emergency Nursing, 45(2), 214–217.

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According to the vignette he received x-rays and was seen by the on-call orthopedic surgeon.

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