A nurse anaesthetist can provide medication care for patients before, during, and after a surgical operation . Typically, people in this profession administer medication to ensure that patients remain asleep or do not experience any form of pain during a surgical process . They monitor the overall biological function and operations within a patient’s body. As Fynes et al. asserted, the scope of practice of a nurse anaesthetic is to work with physicians, surgeons, and anaesthesiologists to provide the relevant painkillers to patients of all age groups, from young to adults . In this project, a discussion is provided on a case study involving an 81-year-old male who visits a health facility for a laryngectomy. The patient has a DNACPR in place. This paper compares anaesthetic management in a patient with a laryngectomy and how it could differ from a tracheostomy. The patient starts to bleed heavily during the operation, leading to cardiac arrest. The immediate steps that an anaesthetic nurse practitioner would take are discussed in this project while justifying the course of action from ethical and legal lenses.
Anaesthetic Management of a Patient with Laryngectomy and How it Differs from a Patient with a Tracheostomy
Accordingly, laryngectomy is a procedure involving the removal of laryngeal structures such as epiglottis, hyoid, and a significant amount of the upper trachea . Comparatively, a tracheostomy is an opening at the front of the neck, usually done during an emergency process or a planned surgery that involves making an airway for people who cannot breathe on their own or have a blockage that interferes with the breathing process . Notably, laryngectomy and tracheostomy are different procedures where the former affects the larynx and is done when the larynx needs to be separated from the airways. In contrast, a tracheostomy enables one to breathe freely and usually affects the trachea . In these two procedures, anaesthetic management could differ.
Anaesthetic Management of a Patient with Laryngectomy
The anaesthetic procedure in laryngectomy is dependent on the nature of the surgery. A formal investigation should be conducted perioperatively before the administration of anaesthesia. In particular, identifying iron deficiency anaemia is necessary as the condition could cause complications during the laryngectomy procedure . The intravenous route of administering anaesthesia could be preferred with the given timescale of the procedure, and new preparations could have a low anaphylaxis rate. Accordingly, perioperative anaphylaxis is a major cause of morbidity and mortality, and the administration of anaesthesia intravenously could lower this incidence. Further, medical evaluation is necessary for anaesthetic management in a patient undergoing laryngectomy . In particular, conditions such as cardiovascular and respiratory diseases should be identified. Opinions from a cardiology specialist on angina, heart failure, and aortic stenosis may be required before a decision on anaesthesia is made as most patients may need the group and save of blood instead of a full cross match as it may be rare to require transfusion perioperatively . Pulmonary hypertension and right heart disease should also be evaluated in the patient, and when identified, serious considerations should be given to whether the patients are suitable for surgery.
Cardiopulmonary exercise testing is also needed as it may aid risk stratification in patients undergoing laryngectomy . Evaluation of the functional status of the cardiopulmonary system helps in estimating the metabolic equivalents of activity, and failing to reach a certain level could signify risk during the process of administering anaesthesia hence explaining why it is an integral practice in anaesthetic management. Patients and anaesthetics are interested in risk stratification, and laryngectomy is considered an immediate risk surgery . The process does not involve opening the main body cavity, explaining why it is a risky intermediate procedure. In this regard, scoring systems such as SORT (Surgical Outcome Risk Tool) and POSSUM (The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) could help predict morbidity. When neither of these processes is validated in anaesthetic management for laryngectomy, they can serve as useful guides for risk quantification . Regardless, discussion of consent and risk explanation are topical and tailored individually to patients. Tools aiding the stratification of risks are helpful in anaesthetic management.
Fibre optic intubation is the gold standard anaesthetic technique for laryngectomy, but it has certain drawbacks . The process involves inducing the patient with relaxation and intubation using an ET tube with a CMAC video laryngoscope. Nonetheless, certain complications may arise, and it is integral for nurse anaesthetists to identify post-operatively issues such as pain, vomiting, bleeding, thyroid storm, oedema at the laryngeal area, and nausea that are possible complications from the use of this anaesthetic management procedure . Notably, in laryngectomy, anaesthetic management takes place in the operation theatre. It is aided by various instruments such as non-invasive blood pressure monitoring equipment, pulse oximetry, and an electro-diagram connected to a patient . When complications are likely, especially in this case where DNACPR is in place, a central line could be considered, and nerves need to be blocked for nasal fibre-optic intubation, best done using short-acting anaesthetic agents since the procedure may be lengthy and there is a need to allow for adequate airways.
Anaesthetic Management of a Patient with Tracheostomy
A tracheostomy is a procedure done on the trachea, as mentioned. Just like in laryngectomy, pre-operative assessment is needed in tracheostomy. Pre-operative evaluation is the airway does not always correlate with ventilation ease, and the practice of managing airways tends to vary among experts . However, standard anaesthetic management practices involve taking of detailed medical history of a patient and conducting physical examinations while observing clinical symptoms and signs. Patterns of shortness of breath should be identified, and positions that alleviate or worsen obstruction of air pathways should be determined as they could help save the patient during unexpected events that may occur following the administration of anaesthesia . Radiologic imaging of the airways could also be considered in tracheostomy to guide the anaesthesiologists in deciding the most appropriate form of anaesthesia .
Anaesthesia preparation in tracheostomy is done by confirming the already conducted chest x-rays to check the cuff position of the tube and increasing the Fraction of Inspired Oxygen on a ventilator. The next steps involve injecting drugs to relax muscles and sedation, secretion of suctions and turning off the ventilator . The tube should be inserted deeper to avoid rupturing the tube cuff. The last step of anaesthesia preparation entails turning on the ventilation and examining movements in the chest. While fibre-optic intubation is the standard procedure in laryngectomy, a suction catheter may be considered in tracheostomy as it enables therapeutic suction and could promote ventilation to the trachea hence allowing pressure to be delivered to the lungs, thus facilitating adequate respiration.
Steps an Anaesthetic Nurse Practitioner Could Take When the Patient Undergoing Laryngectomy Starts Bleeding
In the case study, the 81-year-old male undergoing laryngectomy started bleeding when the policy was ongoing, leading to cardiac arrest. Bleeding is one of the complications likely to arise during laryngectomy processes. Mahajan et al. indicated that an anaesthesiologist is a perioperative physician, implying that they have the mandate to take care of a patient throughout the surgical experience . A nurse anaesthetic is also in the surgical room to provide different levels of assistance and aid to the anaesthesiologist.
The patient started bleeding profusely during the surgical process, leading to a cardiac arrest. I informed the theatre chain of command of the bleeding and the patient’s situation. The surgeon and anaesthesiologist made different steps to identify the source of the bleeding and stop it. The first step I took as an anaesthetic nurse practitioner was to activate a significant haemorrhage protocol to ensure enough blood at the health centre to be transfused to the patient after the bleeding had been resolved. Also, I continually informed the surgical team of changes in the patient’s vitals, including high blood pressure, body temperature, and cardiac output, among others, as they placed the patient on airway and ventilation support. Mainly, this is to keep them updated on the patient’s situation as they try to stop the bleeding. However, all these interventions were done, bearing in mind that a DNACPR was in place and in the event the patient stopped breathing, attempts to resuscitate them would be avoided.
In anaesthetic management, there are three critical phases: induction, maintenance, and emergency . Induction starts when anaesthesia is administered to a patient and ends once an operating surgeon has made an incision. In the induction phase, anxiety-relieving and nerve-blocking medications are provided to a patient. The next step is maintenance, where an anaesthesiologist, with the aid of an anaesthetic nurse practitioner, remains vigilant for any forms of complications likely to occur during the procedure .
Justification of Course of Action Based on Ethical and Legal Issues Involved
Preoperatively, patients with DNACPR are usually referred to senior members of the surgical and anaesthetic teams to allow for deliberation of the next course of action, which explains why I took the relevant measure of informing the theatre chain of command of the situation first before proceeding towards activating a haemorrhage protocol and other criteria. While at it, the medical team continued to act in the patient’s best interest as they tried to stop the bleeding and manage the cardiac arrest. Different DNACPR options can be undertaken in operation rooms. First, the DNACPR decision can be discontinued, and CPR administered. Secondly, the DNACPR decision could be modified to allow for the use of techniques that align with the help of anaesthesia. Thirdly, no changes are to be made to the DNACPR option, although this choice is not compatible with the endowment of general anaesthesia during a surgical intervention . For the patient’s case, the second option was selected. Techniques proportional to anaesthesia were used, and any monitoring forms were documented since the patient was subjected to airway and ventilation support and the duration of time under that support.
For the patient, initiation of CPR would have been considered an assault and a violation of human rights, considering that a DNACPR (Do not attempt cardiac or pulmonary resuscitation) was in place before the surgical procedure. The interventions given to the patient were based on the non-maleficence ethical pillar, indicating that medical personnel should protect a patient from harm. While this is in place, it is integral to understand and act in ways that respect the patient’s rights DNACPR was in place. Nonetheless, having a DNACPR does not mean not intervening when an adverse or critical situation arises while the patient is in surgery. Instead, it entails acting for the patient’s benefit by not attempting CPR if the patient’s heart stops beating while also ensuring that all measures are taken to ensure that such a critical situation is not arrived at hence explaining why mechanical and airway support measures were employed. According to Dawson and McBrien, providing anaesthesia could be a resuscitation, including inserting intravenous lines, delivering oxygen, manipulating airways, and ventilating the patient’s lungs . Failure to indulge in these acts also could be seen as an effort to constitute euthanasia, which is illegal. Thus, there are some ethical and legal dilemmas during a surgical procedure for a patient with DNACPR in place . The ventilation and airway support did not violate the patient’s rights. They were administered before the patient’s heart stopped beating, almost immediately after the cardiac arrest, as the surgical team tried to stop the bleeding. My role was to update the group on changes in the patient’s vitals.
An anaesthetic nurse practitioner is a professional assistant to an anesthesiologist. The role of an anaesthesiologist is to provide medication and care to a patient before, during, and after a surgical procedure. In this project, a case of an 81-year-old male undergoing laryngectomy is reviewed. Anaesthetic management in laryngectomy varies from a tracheostomy, where different anaesthetic procedures may be required, in addition to the usual processes such as obtaining a patient’s medical records and identifying clinical symptoms. At the same time, in a surgical room, an anaesthetic nurse practitioner’s role is to assist the surgical team in informing the theatre chain of command of any eventualities, monitor vital signs, and provide any help as requested by an anesthesiologist. Lastly, for the patient in the case study, a DNACPR was in place, which posits some legal and ethical dilemmas. Ensuring that ethical and legal standards are followed throughout a surgical process is integral to avoiding issues such as lawsuits.
- Ahuja S, Cohen B, Hinkelbein J, Diemunsch P, Ruetzler K. Practical anaesthetic considerations in patients undergoing tracheobronchial surgeries: A clinical review of current literature. Journal of Thoracic Disease. 2016;8(11):3431–41.
- Cannesson M, Ani F, Mythen MM, Kain Z. Anaesthesiology and perioperative medicine around the world: Different names, same goals. British Journal of Anaesthesia. 2015;114(1):8–9.
- Chotipanich A. Total laryngectomy: A Review of Surgical Techniques. Cureus. 2021;13(9):e18181. doi: 10.7759/cureus.18181
- Dawson S, McBrien M. Management of ‘do not attempt cardiopulmonary resuscitation’ (Dnacpr) decisions in the perioperative period. Journal of Perioperative Practice. 2015;25(7-8):126–8.
- Fernandez-Bussy S, Mahajan B, Folch E, Caviedes I, Guerrero J, Majid A. Tracheostomy tube placement. Journal of Bronchology & Interventional Pulmonology. 2015;22(4):357–64. doi: 10.1097/LBR.0000000000000177
- Fritz Z, Slowther A-M, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017; doi: 10.1136/bmj.j813
- Fynes E, Martin D, Hoy L, Cousley A. Anaesthetic nurse specialist role: Leading and facilitation in clinical practice. Journal of Perioperative Practice. 2014;24(5):97–102. doi:10.1177/175045891402400502
- Goodhart IM, Andrzejowski JC, Jones GL, Berthoud M, Dennis A, Mills GH, et al. Patient-completed, pre-operative web-based Anaesthetic Assessment Questionnaire (Electronic Personal Assessment Questionnaire pre-operative). European Journal of Anaesthesiology. 2017;34(4):221–8.
- Gosling AF, Bose S, Gomez E, Parikh M, Cook C, Sarge T, et al. Perioperative considerations for Tracheostomies in the era of COVID-19. Anesthesia & Analgesia. 2020;131(2):378–86. doi: 10.1213/ANE.0000000000005009
- Khera KD, Blessman JD, Deyo-Svendsen ME, Miller NE, Angstman KB. Pre-anaesthetic medical evaluations: Criteria considerations for telemedicine alternatives to face-to-face visits. Health Services Research and Managerial Epidemiology. 2022;9:233339282210748.
- Kristoffersen EW, Opsal A, Tveit TO, Berg RC, Fossum M. Effectiveness of pre-anaesthetic assessment clinic: A systematic review of randomised and non-randomised prospective controlled studies. BMJ Open. 2022;12(5).
- Mahajan A, Esper SA, Cole DJ, Fleisher LA. Anesthesiologists’ role in value-based perioperative care and healthcare transformation. Anesthesiology. 2021;134(4):526–40.
- Michalowski S, Martin W. DNACPR decisions: Aligning law, guidance, and Practice. Medical Law Review. 2022;30(3):434–56.
- Stephens M, Montgomery J, Urquhart CS. Management of elective laryngectomy. BJA Education. 2017;17(9):306–11.
- Omole OB, Torlutter M, Akii AJ. PREANAESTHETIC assessment and management in the context of the District Hospital. South African Family Practice. 2021;63(1). doi: 10.4102/safp.v63i1.5357
- Peng F, Peng T, Yang Q, Liu M, Chen G, Wang M. Pre-operative communication with anaesthetists via Anesthesia Service Platform (ASP) helps alleviate patients’ pre-operative anxiety. Scientific Reports. 2020;10(1).
- Riggs KR, Segal JB. What is the rationale for pre-operative medical evaluations? A closer look at surgical risk and common terminology. British Journal of Anaesthesia. 2016;117(6):681–4.
- Umesh G, Bhaskar SB, Harsoor SS, Dongare PA, Garg R, Kannan S, et al. Pre-operative investigations: Practice guidelines from the Indian Society of Anaesthesiologists. Indian Journal of Anaesthesia. 2022;66(5):319.
- Wacker J, Staender S. The role of the anesthesiologist in Perioperative Patient Safety. Current Opinion in Anaesthesiology. 2014;27(6):649–56.
- Zhang X, Cavus O, Zhou Y, Dusitkasem S. Airway management during anaesthetic induction of Secondary Laryngectomy for Recurrent Laryngeal Cancer: Three cases of report and analysis. Frontiers in Medicine. 2018;5.
- Hiramatsu M, Nishio N, Ozaki M, Shindo Y, Suzuki K, Yamamoto T, et al. Anesthetic and surgical management of tracheostomy in a patient with covid-19. Auris Nasus Larynx. 2020;47(3):472–6.