• Internal Code :
  • Subject Code : CNA532
  • University : University of Tasmania
  • Subject Name : Healthcare

GENERAL ANESTHESIA

Introduction:

The selection of an appropriate mode of anesthesia (induction of patient) is a very important aspect of surgeries as it can result in mortality or mobility incidents. In this assessment, the various aspects associated with general anesthesia (GA) will be explored in-depth with the help of Mr. Oliver case study.  Mr. Oliver Smith was a 62-year old male patient who has been admitted to the hospital for left inguinal hernia repair.  The past medical history of the patient revealed that he had the complication of ischemic heart disease, CABG and hypertension which was managed by medications. The patient had no reported allergies and had received GA in pats with no complications. The patient was no regular aspirin tablets which were stopped 10 days before the surgery.  In the assessment, brief pathophysiology of inguinal hernia along with steps of the surgical process, the rationale of choosing GA and risks associated with the patient will be discussed in detail.  

Discussion:

According to Öberg et al. (2017), the pathophysiology of inguinal hernia is associated with degeneration and alteration in fat content of posterior wall or inguinal floor of Hesselbach triangle. This leads to development of preperitoneal fat and fats on bladder (Öberg et al. 2017). This extends into scrotum and leads to filling of abdominal contents or bowel contents in this empty sac and results in the development of a visible bulge (Öberg et al. 2017).  This leads to sensation and pain in the region which can progress in discomfort and requires surgical treatment (Hammoud and Gerken 2018). 

The surgical procedure for inguinal hernia repair includes use of anesthesia followed by placement of patient in a supine position with tucked arms against side (Hammoud and Gerken 2018).  This has been followed with total extraperitoneal repair, incisions, trocars placement, medial and lateral dissections, placement and mesh fixation, umbilical puncture, port placement, content reduction, peritoneal dissection, peritalisation, mesh placement, fixation of mesh, peritoneal closure and port closure (Sheth and Modh 2018).  The case study revealed that anesthetist chose full relaxant GA for the induction of patient which was done by intravenous administration of propofol.  According to Brown et al. (2011), GA is the most common method which has been used by anesthetist for the induction of patient before surgery.  The GA is a method of developing a drug-induced state of amnesia, immobility, unconsciousness and antinociception along with maintained physiological stability (Brown et al. 2011).  The rationale of using GA over the other methods like regional anesthesia or local anesthesia is that it helps in achieving adequate anesthetic effects for a prolonged time which are not possible with other methods of anesthesia (Smith and Goldman 2018). The procedures of GA are least invasive and painful as compared to other methods and it is an effective therapy for uncooperative patients. There are no significant contradictions associated with GA which increases its significant use in anesthesiology (Smith and Goldman 2018).   The use of GA is most favorable because it facilitates rapid administration and is reversible. Also, it allows use of muscle relaxants with it and allows full control over breathing, airway and circulation (MacDonald et al. 2012).  Also, it has a rapid onset, high lipid solubility and can penetrate the blood-brain barrier easily (Weavind et al. 2017). The GA has more proportion of cardiac output which makes it more preferable for Mr. Oliver as he has medical history of ischemic heart disease, hypertension, CABG and obesity.

For the induction of Mr. Oliver and to achieve antinociceptive effects, the anesthetist used propofol. It has been reported that propofol is a potential hypnotic agent that does not act directly on the nociceptive pathway by decrease nociceptive stimuli perception by inducing unconsciousness (Brown et al. 2018). Primarily the targets of propofol are (GABAA) receptor synapses of interneurons which are inhibitor in nature and located in thalamus, cortex spinal cord, striatum and brainstem and This drug blocks acetylcholine release and develop the desired effects (Chidambaran et al. 2015). The midazolam and fentanyl were also given to the patient before induction for the alleviation of anxiety and management of amnesia unconsciousness (Brown et al. 2018).  The muscle relaxant which was used along with GA for Mr. Oliver was rocuronium. It is a neuromuscular blocker which non-depolarizing and induces muscle relaxation effects during surgery.  It also helps in airway muscle paralysis to help in endotracheal intubation among anesthetic patients (Jain and Maani, 2019).  The sevoflurane was also given to the patient for the prolonging the anesthesia. It is a2-pore potassium channel blocker which provides antinociceptive effects during induction of patients (Brown et al. 2018). 

The anesthetist considered all the pros and cons associated with GA during the surgery of Mr. Oliver but till there were certain risks associated with him and usage of GA for induction of the patient. The Mallampatti score of the patient was 3. According to Khan et al. (2015), high Mallampatti score indicates the patency of airway of patients who are undergoing anesthetic procedures. The high score of Mallampatti manifests the vulnerability for the patient to inadequate intubation because of the only soft palate and base uvula visibility (Mahmoodpoor et al. 2017). The inadequate intubation during GA can lead to catastrophic events like a neurological compromise among patients (Khan et al. 2015). 

Also, the patient has BMI 34 Kg/m2 which indicates his obesity. Gebremedhn et al. (2014) Stated that patients having BMI more than 25 Kg/m2 are prone to ventilation-perfusion mismatch due to low oxygen reserves. The increased fats of obese patients on abdominal area increases pressure and displaces diaphragm in upwards direction and leads to low oxygen reserves which consequently leads to desaturation during induction of patients and may result in compromised respiration and adverse events (Shashaty and Stapleton 2014; Applegate et al. 2016).  

Conclusion:

In this assessment, it has been found that inguinal hernia is complication which can be treated by surgical processes. The selection of an adequate method of patient induction is very significant for the prevention of adverse events. It has been found that GA is a safe and appropriate method for the patients like Mr. Oliver because of its applicability, allowance of muscle relaxants, rapid onset and high lipid solubility. It is a drug-induced state of amnesia, immobility, unconsciousness and antinociception which can be used for induction of patients for surgery.  Moreover, it has been found that the patient was vulnerable to catastrophic events due to obesity and high Mallampatti score. 

References:

Applegate, R.L., II, I.L.D., Wells, B., Juma, D. and Applegate, P.M. 2016. The relationship between oxygen reserve index and arterial partial pressure of oxygen during surgery. Anesthesia and Analgesia, 123(3), p.626.

Brown, E.N., Pavone, K.J. and Naranjo, M. 2018. Multimodal general anesthesia: Theory and practice. Anesthesia and Analgesia, 127(5), p.1246.

Brown, E.N., Purdon, P.L. and Van Dort, C.J., 2011. General anesthesia and altered states of arousal: A systems neuroscience analysis. Annual Review of Neuroscience, 34, pp.601-628.

Chidambaran, V., Costandi, A. and D’Mello, A., 2015. Propofol: A review of its role in pediatric anesthesia and sedation. CNS Drugs, 29(7), pp.543-563.

Gebremedhn, E.G., Mesele, D., Aemero, D. and Alemu, E. 2014. The incidence of oxygen desaturation during rapid sequence induction and intubation. World Journal of Emergency Medicine, 5(4), p.279.

Hammoud, M. and Gerken, J., 2018. Hernia, Inguinal. In StatPearls [Internet]. StatPearls Publishing.

Jain, A. and Maani, C.V., 2019. Rocuronium. In StatPearls [Internet]. StatPearls Publishing.

Khan, Z.H., Eskandari, S. and Yekaninejad, M.S. 2015. A comparison of the Mallampati test in supine and upright positions with and without phonation in predicting difficult laryngoscopy and intubation: A prospective study. Journal of Anaesthesiology, Clinical Pharmacology, 31(2), p.207.

MacDonald, S.J., Somerville, L., Howard, J., Naudie, D.D., McAuley, J., McCalden, R. and Bourne, R., 2012, September. Spinal vs general anesthesia in THA: An analysis using prospectively collected clinical patient data. Orthopaedic Proceedings, 94, (XXXVIII), pp. 115-115.

Mahmoodpoor, A., Soleimanpour, H., Golzari, S.E., Nejabatian, A., Pourlak, T., Amani, M., Hajmohammadi, S., Hosseinzadeh, H. and Esfanjani, R.M. 2017. Determination of the diagnostic value of the Modified Mallampati Score, Upper Lip Bite Test and Facial Angle in predicting difficult intubation: A prospective descriptive study. Journal of Clinical Anesthesia, 37, pp.99-102.

Öberg, S., Andresen, K. and Rosenberg, J., 2017. Etiology of inguinal hernias: A comprehensive review. Frontiers in surgery, 4, p.52.

Shashaty, M.G. and Stapleton, R.D., 2014. Physiological and management implications of obesity in critical illness. Annals of the American Thoracic Society, 11(8), pp.1286-1297.

Sheth, J.Y. and Modh, F.A., 2018. Laparoscopic inguinal hernia repair: a prospective study of 120 cases. International Surgery Journal, 5(8), pp.2904-2909.

Smith, G. and Goldman, J., 2018. General Anesthesia for Surgeons. In StatPearls [Internet]. StatPearls Publishing.

Weavind, L., MBBCh, F.C.C.M. and MMHC, K.A., 2017. General anesthesia: Intravenous induction agents.  Retrieved from https://www.uptodate.com/contents/general-anesthesia-intravenous-induction-agents

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