Systematic Review of Perioperative Care

This assignment requires a systematic review of perioperative care practices, including the analysis of various studies and papers on topics such as patient safety, pain management, and surgical techniques. The assigned readings include articles from journals such as Clinical Gastroenterology and Hepatology, British Journal of Surgery, and European Journal of Anaesthesiology. The review should provide an overview of the current best practices in perioperative care, including guidelines for patient preparation, anesthesia, surgery, and post-operative recovery. The assignment aims to identify key findings and recommendations from the literature, providing a comprehensive understanding of perioperative care protocols.

Running head: PERIOPERATIVE CARE CASE STUDY
Peri-operative Care Case study
Name of Student
Name of University
Author Note

1PERIOPERATIVE CARE CASE STUDY
The purpose of this paper is to review the care taken of a 38-year-old female patient who
underwent a laparoscopic cholecystectomy. The discussion will focus on the brief description of
the patient’s medical history, journey of the preoperative, intra-operative and post operative
surgical procedures as well as the methods used by the healthcare providers to address patient
safety, communication between the service care providers and efficacy of the teamwork among
the system (Halverson et al. 2011 pp.305-310). Peri-operative care is a critical procedure that
requires skilled professionals who can perform effective clinical assessment, surgical
requirements and strict monitoring after the operation until the patient fully recovers (Krajewski
et al. 2014pp.24-36). The whole process starts with preliminary assessment to determine the
problem with the patient and devise a plan of action before commencing the surgical procedure
(Nygren et al. 2012pp.801-816). During this time, a team is formed which consists of a surgeon,
an anaesthetic nurse, an anaesthetist, a circulating and scrub nurses. It is the duty of the
registered nurses to look after the patient and monitor for any signs of distress. The paper will
reflect on the mistakes of the procedure and support with evidence based research to understand
the implications of clinical mal practice.
The patient is a 38-year-old woman named Olivia Randell, who had been suffering for
the previous six months with pain and discomfort on her right hand side of hypochondrium. She
came in with bitter taste in her mouth, nauseous, releasing gas from her upper gut, burning
sensation in heart and alternative diarrhoea and constipation like conditions. The physician
diagnosed her with acalculous cholecystitis on analysis of ultrasound report of gallbladder scan
(Huffman and Schenker 2010pp.15-22.). The report showed that the patient’s gall bladder lining
has thickened to form 6mm sludge like structure obstructing functionality. The patient had been
referred to a surgeon who suggested laprascopic cholecystectomy (Tsimoyiannis et al.

2PERIOPERATIVE CARE CASE STUDY
2010pp.1842-1848). The patient underwent a laparoscopic sleeve gastrectomy prior to this
surgery to lose weight by restricting the stomach food intake (Eid et al. 2012pp.262-265). This
procedure lowered her basal metabolic rate (BMI) from 40 to present day 30. Frequent hydration
was the given advice to the patient after her weight loss procedure. The previous procedure of
the patient subjected her to post operative vomiting and nausea (PONV) which was not properly
addressed in the previous healthcare setting (Apfel et al. 2012 pp. 742-753). She was worried
about the repetition of the same incident after the current procedure as well and was anxious
about it, as she did not have prior acquaintance with the surgical crew, which she mentioned to
the anesthetist (Jlala et al. 2010 pp.369-374).
The first pre-operative mistake observed in the following situation, is that the anesthetic
nurse who noticed that the consent form was completed by the ward nurse but the signature of
the patient was missing. The anesthetist questioned the ward nurse to whom she replied that she
was not the assigned nurse for the patient, only helped her move into the operation theatre
(Jeyaseelan et al. 2010 pp.407-408). The anesthetic nurse was quick to make sure that the patient
was completely aware of the procedure about to performed on her, to which the patient
responded positively after which the patient was escorted to the anesthesia ward.
The traditional intraoperative surgical crew consists of an experienced surgeon, an
anesthetist, circulating nurse and scrub nurses. The surgeon was experienced with laprascopic
cholecystotectomy for 25 years. The anesthetist was a registered nurse whom the surgeon was
training under the supervision of consultant who was then working in another operation theatre.
The surgeon and the anesthetist did not have any prior professional acquaintance or familiarity.
The usual scrub nurse assigned to the surgeon was on leave due to illness that day and
replacement was an experienced nurse from agency, but had not previously worked for the

3PERIOPERATIVE CARE CASE STUDY
current hospital. The circulating nurses was professionally acquainted with the surgeon and his
working procedure abut was then supervising a registered nurses who was in her preliminary
weeks of practice in the operation theatre. The operation list arrived late due to unavailability of
instrument supply while another operation was taking place.
Anesthesia was performed using a combination of 1.5 mg/kg Propofol Intra Vitreal
Injection (IVI) of bolus, using 1.5 mcg/kg fentanyl, 0.03 mg/kg midazolam, and 0.01 mg/kg
vecuronium. The oxygen maintenance was provided with a ProSeal laryngeal mask airway
(LMA) (Seet et al. 2010 pp.602-607). Anaesthesia was kept with sevoflurane and 50% N20/O2
ventilation, and a blend of Propofol (75 mcg/kg/min) and remifentanil (0.05 mcg/kg/min
infusion). Intra-operative checking was done using standard procedures which comprised of
using non-invasive blood pressure, ECG, pulse oximeter, end tidal carbon dioxide (ETCO2), and
thermal measurement. The anesthetist was at that time concerned that during initial mask
aeration the patient’s abdomen had insufflation from previous weight loss surgery (Chaudhuri et
al. 2012 pp.646-653). IVI Cefazolin 2 g administered immediately adjacent to the previous
incision. The patient was in supine position, and later positioned to reverse Trendelenburg
(Hathorn et al 2013 pp.308-313). Laparoscopic port insertion and induction of the pneumo-
peritoneum were commenced with CO2 performed after prepping and draping. The circulating
nurse directed the new graduate RN to connect the light, video, and gas leads and to verbalize the
pressure on the insufflator, which was 10 mmHg.
The surgery took one hour instead of the designated 45 minutes due to following issues
of removal of surgical adhesive from the area of the patient from her previous surgery (Rothrock

4PERIOPERATIVE CARE CASE STUDY
2014). The scrub nursed warned the circulating nurse that the procedure might have to do open
surgery. The surgeon requested for an intra-operative cholangiogram, which consumed another
few minutes as the technician was attending another operation theatre. The image intensification
procedure also was delayed, as the operation table was not in proper position.
The patient was administered with 4 mg ondansetron and 8 mg dexamethasone IVI to
prevent PONV, ten minutes prior to the end of procedure (Alghanem et al. 2010 pp.353-358).
The patient experienced, coughing and slight regurgitation, after position reversal and the
anesthetic registrar was worried that the patient has undergone aspiration. After the completion
of the procedure the circulating nurse questioned the RN why surgical “time-out” was not
performed before the procedure but she replied that the new graduate nurse did not mention it in
the beginning (Oszvald et al. 2012 p.E6).
The postoperative description is as follows- The patient transfer was done to Post
operative Anesthetic Care Unit of PACU, the nursing staff who had received the patient felt that
she had not received adequate handover information from the anesthetic RN, who seemed to be
in hurry (Riesenberg Leisch and Cunningham 2010 pp.24-34). However, she did not cross-
question him at the time, but has spoken about it with the in-charge nurse. The Pain Protocol
was followed according to the regulations of the National Inpatient Medication Chart, by
preparing a solution of fentanyl 100 mcg/10mls (normal saline). During the patient’s admission
in PACU her vital signs were within normal level, however her pain and nausea were not
properly treated. She had two episodes of convulsing and gastric aspiration. This left her in tears
and distress. She had received 10mls of Pain Protocol. The consultant anesthetist was called for
checking the patient. He was surprised by the use of an LMA. He ordered for ondansetron 16
mg, metoclopramide 10 mg, prochlorperazine 10 mg, and hydromorphone 1 mg/10mls, and an

5PERIOPERATIVE CARE CASE STUDY
overnight transfer to High Dependancy Unit or HDU (Seet et al. 2010 pp.602-607). After a
couple of hours, she was deemed eligible for discharge although, the patient was in state of
sedation. An afternoon staff member freed the assigned PACU nurse from duty. The patient had
to be kept waiting for the HDU admission, due to unavailability of beds at that time. After taking
the patient to the HDU, the PACU staff member realized that the sedation score had not been
reported in the handover form. The patient was left in temperament, as she wanted to see her
family members who were in the waiting room, even before entering the HDU, which left her
distressed.
The Critical Analysis of the perioperative care is described as follows; firstly, the
problem with the clinical management was that the handover nurse did not make sure whether
the patient had signed the consent form, which would have been problematic if it was left
unnoticed until after the anesthesia. The patient would have had no motor skills to sign the form
and the procedure would have been delayed for hours. It is the duty of assigned nurses to
properly check and assess the consent form and duly fill up according to the situation as soon as
the procedure was finalized (Vather and Bissett 2013 pp.319-324).
The second problem with the procedure was selection of the crewmembers for the
surgical procedure (Oszvald et al. 2012 p.E6). The choice of surgeon had been excellent with lots
of experience in the field, but the rest of the crew including the registered nurse, anesthetist nurse
the anesthetist itself were not acquainted with the surgeon. Only the circulating nurse had
professional acquaintance with the surgeon. It is very difficult for a surgeon to perform a critical
surgery if the crew is not efficient. There were two nurses, one was a newly assigned registered
nurse in her first few weeks of professional career and another nurse was from a different agency
who was accustomed to working the hospital at that time. This is very problematic and lead to

6PERIOPERATIVE CARE CASE STUDY
the development of post operative as well as intra-operative errors due to communication error
(Halverson et al. 2011 pp.305-310). This reflects a bad picture of teamwork in healthcare
services. There was also communication gap between the nurses that lead to further assessment
problems.
The anesthetist nurse was concerned about the already existing insufflated area on the
patient’s body from previous weight loss surgery. She did not speak up and discuss about the
problem, which could avoided the issue of the patient having no time-out sessions to finalize the
procedure to make sure not stones were left unturned before commencement of the procedure
(Oszvald et al. 2012 p.E6). This suggests that the patient’s previous surgery was not properly
recovered which could have lead to further complication after the laparoscopy, this problem was
left un-discussed by the surgeon as well the nursing crew.
There was delay at the time of the surgery due to the fact that, the operational list as well
as the instruments unavailable as they were being used in the operation procedure before this
one. The radiography technician uninformed that he would be needed in the procedure, which
shows lack of presence of clinical decision-making skills in the surgeon’s part and the procedure
had to be halted for ten to fifteen minutes until the technician reached the place (Elwyn et al.
2012pp.1361-1367). Even after that the operation table was not properly adjusted which is the
image detector was not working. This suggests lack of preparation on the crew’s part and shows
that the procedure was done in a hurry. This could have had severe clinical implications and
sepsis could have occurred in the operation theatre (Buck et al. 2013 pp.1045-1049).

7PERIOPERATIVE CARE CASE STUDY
The nurse who received the felt like she did not adequate information from the previous
handover nurse, as the handover nurse was in a hurry and this suggests lack of communication,
or the involvement in the patient care (Halverson et al. 2011 pp.305-310). This is a bad form of
clinical practice, which nurses should avoid. Communication is also another important factor that
keeps the workforce of the healthcare facility supported (Halverson et al. 2011 pp.305-310). It is
important to convey information among the care givers involved in the care plan of a particular
patient. Missing information or withholding information can have severe clinical repercussions.
Nurses always have to provide complete attention to the need of the patient up until their duty
ends. This was not seen in this case. Another point that needed to be mentioned, is that the
handover nurse did not mention or question the previous handover nurse but only mentions it to
the nurse- in charge when questioned about it. This is also an example of communication gap in
the workforce (Halverson et al. 2011 pp.305-310).
The was given LMA, which is sometimes an invasive technique of airway management
leading to gastric aspiration, the patient felt nauseous and belching after the procedure and felt
distressed (Seet et al. 2010 pp.602-607). This could have been avoided or handled properly since,
the patient had a previous trauma regarding postoperative care, but had to go through the anxiety
once again (Gustafsson et al. 2012 pp.783-800). This could have stressed her vitals and clinical
complications could have been enhanced. The consultant anesthetist was surprised at the use of
LMA and gave sedatives to calm her nerves (Seet et al. 2010 pp.602-607). The discharge safety
was not proper, as the patient had not recovered from her anesthesia during her discharge
(Phillips et al. 2013 pp.275-284). The patient had not been allowed to see her family members
who were present in the hospital grounds, which further enhanced her distress.

8PERIOPERATIVE CARE CASE STUDY
The discussion above, points out the many mistakes of the perioperative care unit-
including pre-procedural planning, safe positioning, intra operative nursing considerations, and
pain management as well as importance of communication in a clinical care setting and the affect
it has on the patient outcome. The patient outcome is dependent on the efficacy of the workforce
in the healthcare institution. The clinical experience of the surgeon is not enough to determine
the positive outcome of the patient. The surgical crew had many communication errors and
management issues that lead to delay in surgery which could have been easily avoided. The
patient’s previous insufflations, was rendered unimportant and the handovers were rushed and
lacked attention and responsibility. The lack of time-out before operation could have solved all
of these problems with proper communication, but the registered nurse was new to her
profession but the supervisor also did not notice the fact. There was no investigative committee
to look after this problem. This breaches the standard practice guidelines of the nursing and
midwives board in Australia NMBA. The clause that state practice of safety procedures for
patient safety was not supported. The communication in the team was not good which also
breaches the code of conduct, which uphold communication. The ethical issues can also be
analyzed in this situation, as the nursing staff is obligated to share every information and
complain if another nurse is not standing true to their duty, but this was not reported at that time
and needed mentioning. The clinical practice was very inefficient and patient engagement was
very poor as she was not allowed to meet her family and was left distressed. This also breaks the
ethical conduct and standard guidelines of NMBA.

9PERIOPERATIVE CARE CASE STUDY
References:
Alghanem, S.M., Massad, I.M., Rashed, E.M., Abu-Ali, H.M. and Daradkeh, S.S., 2010.
Optimization of anesthesia antiemetic measures versus combination therapy using
dexamethasone or ondansetron for the prevention of postoperative nausea and vomiting. Surgical
endoscopy, 24(2), pp.353-358.
Apfel, C.C., Heidrich, F.M., Jukar-Rao, S., Jalota, L., Hornuss, C., Whelan, R.P., Zhang, K. and
Cakmakkaya, O.S., 2012. Evidence-based analysis of risk factors for postoperative nausea and
vomiting. British journal of anaesthesia, 109(5), pp.742-753.
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Eid, G.M., Brethauer, S., Mattar, S.G., Titchner, R.L., Gourash, W. and Schauer, P.R., 2012.
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for clinical practice. Journal of general internal medicine, 27(10), pp.1361-1367.

10PERIOPERATIVE CARE CASE STUDY
Gustafsson, U.O., Scott, M.J., Schwenk, W., Demartines, N., Roulin, D., Francis, N., McNaught,
C.E., MacFie, J., Liberman, A.S., Soop, M. and Hill, A., 2012. Guidelines for perioperative care
in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society
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Hathorn, I.F., Habib, A.R.R., Manji, J. and Javer, A.R., 2013. Comparing the reverse
Trendelenburg and horizontal position for endoscopic sinus surgery: a randomized controlled
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completion in orthopaedics: are we just going through the motions?. Journal of medical
ethics, 36(7), pp.407-408.
Jlala, H.A., French, J.L., Foxall, G.L., Hardman, J.G. and Bedforth, N.M., 2010. Effect of
preoperative multimedia information on perioperative anxiety in patients undergoing procedures
under regional anaesthesia. British journal of anaesthesia, 104(3), pp.369-374.
Krajewski, M.L., Raghunathan, K., Paluszkiewicz, S.M., Schermer, C.R. and Shaw, A.D., 2015.
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resuscitation. British Journal of Surgery, 102(1), pp.24-36.

11PERIOPERATIVE CARE CASE STUDY
Nygren, J., Thacker, J., Carli, F., Fearon, K.C.H., Norderval, S., Lobo, D.N., Ljungqvist, O.,
Soop, M. and Ramirez, J., 2012. Guidelines for perioperative care in elective rectal/pelvic
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‐Based Healthcare, 11(4), pp.275-284.
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Seet, E., Rajeev, S., Firoz, T., Yousaf, F., Wong, J., Wong, D.T. and Chung, F., 2010. Safety and
efficacy of laryngeal mask airway Supreme versus laryngeal mask airway ProSeal: a randomized
controlled trial. European Journal of Anaesthesiology (EJA), 27(7), pp.602-607.
Tsimoyiannis, E.C., Tsimogiannis, K.E., Pappas-Gogos, G., Farantos, C., Benetatos, N.,
Mavridou, P. and Manataki, A., 2010. Different pain scores in single transumbilical incision
laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized
controlled trial. Surgical endoscopy, 24(8), pp.1842-1848.

12PERIOPERATIVE CARE CASE STUDY
Vather, R. and Bissett, I., 2013. Management of prolonged post‐operative ileus: evidence‐based
recommendations. ANZ journal of surgery, 83(5), pp.319-324.