Operating Room Clinical Intensive Case Study

Operating Room Clinical Intensive Case Study

Chung H Yi

University of New Mexico

N415

PATIENT HISTORY

K.C. is a three year old white Anglo who weighs 36 pounds, and is 3"2' tall. This English speaking child was born via C -section, due to placental issues, weighing 7 pounds 7 ounces. The mother has indicated that all development was "completely normal", in that K.C. was walking at 10 months of age. At the age of three, the child was presented with a left trigger thumb. The mother noticed this for several months, but is unclear when the onset started to happen. It was noted after a fall of the child that she complained of pain and then noted that she was not able to extend her thumb.

The patient has a medical history including, but not limited to, imperforate anus (which has been reconstructed), a coarctation of the coronary vessels (which could have been lead to imperforate anus), and most recently an ear infection and pink eye, which is almost completely resolved.

The family history includes a brother who is currently afflicted with allergies, and a mother who is pre-diabetic. K.C. is not is not currently on any medications, however has an allergy to Lortab, more frequently known as acetaminophen; this medication causes an allergic of hives.

SURGICAL PROCEDURE AND RATIONALE

K.C.'s past medical history has no direct correlation as to why she is having her surgery. Although there is no known etiology of a left trigger thumb, K.C. had fallen, and afterwards complained of pain in her left trigger thumb. The child was not able to extend the thumb beyond her current position, which is 30-degrees at the IP joint. She has no ability to extend her thumb, and is in no apparent distress. Also noticed, was a prominence at the base of the thumb. The inability to extend the trigger thumb is easily and readily treatable. The recommendation is a trigger thumb release in which the A1 pulley, which is used to keep the tendons close to the bone, is relieved and allowed for more flexibility.

The patient presented with the thumb flexed in a fixed position, not being able to extend the thumb. This is caused by significant force at the A1 pulley and tendon, which is where the trigger thumb occurs. The tendon and A1 pulley both show inflammation and a change in a substance called fibrocartilaginous metaphasia. The cells show characteristics of a cartilage, and not the smooth gliding layer of the tendon or pulley. Treatment for this child's left trigger thumb was recommended by the doctor to have a surgical operation on the left thumb.

Before the surgical procedure is to happen, the patient is held in the pre-operative area. This is where the child has her vital signs checked and put in proper hospital attire. A complete overview of the procedure is discussed with the child's mother, surgeon, nurse, and anesthesiologist. The nurses in pre-op check to make sure all required consents were appropriately signed, as well as other documents.

The surgical procedure starts by the patient lying in a comfortable supine position. The child must breathe in Sevoflurane (used in children due to less irritation, and faster onset) put them to sleep, than an IV was inserted on the right forearm. The patient is given propofol, which puts them at an unconscious state to maintain general anesthesia. To keep the body temperature of the child normothermic, a bair hugger was used to keep them warm during the procedure. Chlorohexidine is applied over the whole hand plus arm up to the elbow. Once the procedure begins an incision (2cm) is made at the base of the thumb to reveal the pulley. The pulley is then cut to release the locked/flexed tendon. The surgeon then tugs on the A2 pulley to make sure flexion still occurs with the thumb. The incision is sutured and the operation was a complete success.

INTRAOPERATIVE PHASE

The desired outcome of this surgery is to allow full thumb flexibility. The goals that are hoped to be achieved are: no signs of infection due to surgical procedure (maintain sterile procedure), no recurrence of the triggering, damage to local structures, no impaired skin integrity due to positioning, maintain normothermia, minimum pain symptoms, and low blood loss. Complications that are involved with the procedure can be failure to relieve triggering, hypothermia, and respiratory depression due to over sedation. This is why the anesthesiologist monitors the vital signs while the procedure is being performed.

After the surgeon has completed the operation, the patient is then taken to the PACU unit. The PACU unit is the recovery area where immediately they are placed to monitor and take vital signs. A complete assessment is performed to make sure pain is treated, as well as, PONV and other complications. In this patient's case, the pain level was