Perioperative Care Overview

Introduction

The perioperative care is referred to the care support delivered to the patients before, during and after the surgery to minimise any risk related to their health during and after the surgery (Loozen et al. 2017). In this essay, the perioperative practice is to be discussed in the context of a patient undergoing laparoscopic cholecystectomy. In the UK, nearly 50,000 laparoscopic cholecystectomy is performed every year among which 1/3rd is performed for managing cholecystitis (NICE, 2018). This indicates that it is one of the frequently performed surgical procedures in the UK (NICE, 2018). Thus, the discussion of perioperative care in the context is important to aware patients regarding the measures taken for its effective execution. This is because it is going to assist patients and families trying to undergo the surgery to make easier and effective decision for availing it. The assignment will be a case study of a patient, undergoing laparoscopic cholecystectomy. The evidence base of care and care delivery is to be discussed along with the roles and responsibilities of the operating department practitioner in the care for the patient. The communication issues encountered in the practice area are also considered and discussed, which can be addressed through healthcare dissertation help.

Case Study

According to section 5 of the HCPC Code of Conduct, no personal details of the patients are to be shared without their prior consent to maintain confidentiality. The sharing of the patient's data is only to be made with the responsible professionals in need of care assistance and ensuring well-being of the patient (HCPC, 2018). Thus, to protect the identity of the patient a pseudonym M is to be used for indicating the patient. The patient M who is 70 years old and lives alone in her house was admitted to the hospital due to feeling of severe pain in the upper right part of the abdomen for the past three days which was initially moderate pain for the past 3 months. She also expressed symptoms of fever, indigestion, diarrhoea, vomiting and nausea. She initially used to take pain killers to minimise the pain but for the past three days increased complication along with severe pain is being felt. The symptoms of Cholecystitis include pain in the upper right region of the abdomen, indigestion, fever, vomiting and others (Bridges et al. 2018). On the basis of the information and M’s analysis, the initial review of the condition to be Cholecystitis.

In Cholecystitis, gall stones are developed which blocks the pathway of releasing bile leading it to build-up inside the organ causing inflammation (Bridges et al. 2018). An abdominal ultrasound was performed for M where the pictures revealed presence of many stones in the gall bladder along with being highly inflamed. This alerted the health practitioner to suggest M immediately perform laparoscopic cholecystectomy. The laparoscopic cholecystectomy is surgical method used for removal of gallbladder in which small incision is done and through the use of small camera and specialised surgical tool the operation is performed (Goyal et al. 2017). The perioperative care is required for the patient M undergoing laparoscopic cholecystectomy to ensure any risk towards their health before, during and after the surgery is avoided due to the surgical process. Thus, the perioperative practise in the context of laparoscopic cholecystectomy for M is to be discussed.

Discussing care of the patient

The section 7 of HCPC Code of Conduct informs health professionals to put the safety and well-being of the patient during care before their personal concerns (HCPC, 2018). Thus, in perioperative care for M, the OPD nurse is to ensure safety regarding her care on admission to the hospital. According to the National Patient Safety Agency (NPSA), the five steps to patient safety in surgical process are briefing, sign-in, timeout, sing-out and debriefing (NPSA, 2011). In the briefing stage, the roles of team members in perioperative care are discussed along with the tools to be required for the surgical process (NPSA, 2011). This is because it would provide clear concept regarding the resources required and responsibilities to be performed by each member of the surgical team to ensure well-being of the patients. As argued by Alfa-Wali and Osaghae (2017), lack of effective determination and presence of surgical tools during surgery develops error in care and patient safety issues. This is because without required tools effective approaches are unable to be taken by the surgeon in performing the procedure in unhindered way that creates safety issues for patients.

In laparoscopic cholecystectomy for M, the key tools required are laparoscope, needle driver, trocar and bowel grasper. The laparoscope is the instrument which involves a viewing device, CCD camera, lens cleaner and energy-supply device that are used to view inside the body for removing the gallbladder. It is inserted inside the body through small incisions (4 incisions of one inch or less length) near the right part of the abdomen where the gall bladder is located (Madani et al. 2017). Thus, it is the key device in surgical procedure of M through which internal view of the body is to be made for removing the gall bladder. The needle driver is used in laparoscopic surgery for holding suture needle for closing wounds or incisions (Watanabe et al. 2016). This is used for M‘s surgery to ensure the incisions made for inserting laparoscope are closed to avoid bleeding.

The trocar along with the scalpel, probe and cannula are used in laparoscopic cholecystectomy to safely manipulate delicate tissues in the abdomen so that adequate access to the site of surgery can be reached for performing the procedure effectively (Nofal et al. 2020). Thus, trocar is used for laparoscopic cholecystectomy in M so that operating field in the body is efficiently identified and accessed in successfully performing the surgery. The bowel grasper is used to allow surgeon grasp and manage abdomen tissues to observe and execute surgical procedures on organs located internally (Roy et al. 2020). In case of M, the gall bladder is located on the right part of the abdomen internally and during laparoscopic cholecystectomy use of grasper is going to help the surgeon in manipulating the abdomen tissue to reach the gall bladder for performing surgery.

The team members present in laparoscopic cholecystectomy for M include operating department practitioner (ODP), anaesthesia nurse, surgical nurses and surgeon. The role of ODP in surgical procedure is to prepare necessary equipment and environment for the anaesthetic, surgery and recovery of the individuals from the surgical procedure (Isreb et al. 2020). The anaesthesia nurses have the role to administer anaesthesia to the patient and surgical nurses assist surgeons in performing their role of executing the surgery (Melloy et al. 2016). Thus, in laparoscopic cholecystectomy for M, the ODP would set the surgical environment for M, anaesthesia nurse would administer anaesthetic and medication along with surgical nurses has the role to assist the surgeon who is going to perform the surgery for M. As argued by Xiaolan et al. (2018), role of each member in surgical team is to be informed in detail so that no confusion arises in the process which may hinder the safety of the patient. This is because lack of role demarcation for the surgical team leads them to remain confused regarding the responsibility to be managed by each of them which in turn leads to duplication and error in care creating safety issues for the patient in the procedure.

In sign-in stage, the prophylactic antibiotics and anaesthetic to be given for the patient are determined and administered (NPSA, 2011). At this stage for M, the medications and anaesthetic required are to be arranged. The prophylactic medication is used to avoid surgical site infection and amphicillin-sulbactam along with ciproflaxion is infused in M for cholecystectomy after surgery to ensure avoidance of any infection in the surgical site (Gomez-Ospina et al. 2018). The anaesthesia is used in surgical procedure for controlled and temporary loss of sensation to avoid pain from incision and other activities in the procedure (Chauhan et al. 2018). In case of M, during her laparoscopic cholecystectomy surgery, general anaesthetic is provided as per NHS guidance which indicates that during the entire surgical procedure M will be sleeping without feeling any pain (NHS, 2018). The general anaesthetic used in laparoscopic cholecystectomy includes short-acting drugs like propofol, vecuronium, atracium and others (Gomathi et al. 2018).

In general anaesthesia for laparoscopic cholecystectomy, endotracheal intubation is used for controlled ventilation (Singh et al. 2019). In case of M, the intubation is used for helping her to breath effectively during the procedure. This is because during general anaesthesia the parts of the body such as diaphragm and others paralyze making the patient depend on ventilation for breathing (Allu et al. 2019). The local anaesthesia is referred to inducing absence of sensation of a particular area of the body whereas regional anaesthesia is referred to numbness in large part of the body such as numbing lower part of the body from waist down (Nijhawan et al. 2018; Wahal et al. 2018). As argued by Bajwa and Kulshrestha (2016), local and regional anaesthesia is rarely used in laparoscopic cholecystectomy. This is because in these procedures the patient remains half awake and may face trauma by watching the surgical process making the face collapse heart, nausea, blurred vision, tremor and other. Thus, to avoid such issues local and regional anaesthesia is not used for M but they can be used if M avoids general anaesthesia in which there is risk of getting back to consciousness.

In timeout stage, the correct surgical site for surgery is identified (NPSA, 2011). The study by Evers et al. (2017) mention that in laparoscopic cholecystectomy surgery four small incisions are made at the right upper part of the abdomen which is just below the liver. Thus, in case of M, incisions are to be made at the right upper part of the abdomen. The insufflation of the abdomen of the patient in laparoscopic cholecystectomy surgery is done in which a gas mainly carbon dioxide is inserted into peritoneal cavity to develop pneumoperitoneum. After insufflations, the patient is placed in reverse Trendelenburg position with right side up for proceeding to perform the surgery initiating with incision (Khalil and Nada, 2017). Since M is undergoing laparoscopic cholecystectomy, the following position is to be maintained. The importance of reverse Trendelenburg position in laparoscopic cholecystectomy is that it allows effective exposure of the surgical site and minimise invasive upper abdominal procedures (Moon et al. 2020).

In sign-out stage, the critical steps of the surgical procedure are discussed for the patient to determine approaches to be followed in the procedure (NPSA, 2011). This is because it would make the surgical team alert about the steps to be followed effectively to avoid any adverse effect on the health of M before, during and after the surgery. The room temperature of the operating theatre where the anaesthesia and surgery of M in laparoscopic cholecystectomy is performed need to more than 24˚C. This is to avoid heat loss from the body resulting in hypothermia which adversely affects the nervous and respiratory system along with other organs leading patient to face fatal condition (Jo et al. 2016). Thus, the operating room of M is to remain adequately ventilated and warm to ensure avoiding risks of hypothermia.

The airflow to and fro the surgical suite where laparoscopic cholecystectomy is performed needed to be 25 air volume changes per hour. This is to ensure dilution of airborne microorganisms in the surgical room developed with human activity in air to be removed to avoid creating an infectious environment (Aganovic et al. 2019). This is required for M to avoid development of infection in the surgical site due to the environment. As argued by Baradaranfard et al. (2019), anaesthesia leads the core body temperature to be reduced by 1-1.5˚C. Thus, during the entire surgical process body temperature of M is to be monitored to ensure avoiding any sudden fall in temperature that indicates patients to experience hypothermia. In brief, laparoscopic cholecystectomy is performed with insertion of laparoscope through one incision and insertion of other tools (trocar, needle) for operation through three other incisions. The surgeon with the help of laparoscope locates the surrounding structure and manipulates other surgical instruments to cut gall bladder from the cystic duct area. The gall bladder is then drawn out from one of the incision and the cuts are closed through stitches (Cox, 2018).

In debriefing stage, the problems to be encountered by patients before, during and after the surgical procedure is determined and discussed to ensure taking steps to resolve them (NPSA, 2011). In order to determine the problems to be faced in the laparoscopic cholecystectomy of M, risk assessment is performed. The risk assessment in surgical process of laparoscopic cholecystectomy indicates that risk is faced with wrong positioning of the patient, diathermy burns, infection, hypothermia, unintentional retainment of object inside the body and deep vein thrombosis (DVT) (Goyal et al. 2017). The wrong positioning of the patient, in this case of M, can be avoided during the surgery by positioning the patient with collaboration and supervision of multi-disciplinary team in the surgical room. In laparoscopic cholecystectomy, the diathermy burns may occur outside the laparoscopic field due to electrothermal effect (Hu et al. 2017). The diathermy burn risks can be avoided if the surgeon remains away from grounded metal objects during the surgical procedure (Siddaiah-Subramanya et al. 2017). In this condition, any loose-fitting jewellery on M as well as surgeons operating are to be removed and exposure to metal parts is to be avoided.

The risk of infection and hypothermia can be avoided for M during and after the surgical procedure by maintaining hygienic environment along with proper airflow and room temperature in the operating theatre. As argued by Friend et al. (2018), use of unsterilized surgical instruments in surgery raises risk of infection of wounds. Thus, the surgical instruments to be used are to be adequately sterilised before its use to avoid development of infection for M. The surgeon after laparoscopic cholecystectomy is to monitor the internal area before drawing put the laparoscope to avoid retainment of any instruments in the body (Goyal et al. 2017). In laparoscopic cholecystectomy, the deep vein thrombosis can be avoided by use of thromboembolic prophylaxis medication such as subcutaneous nadroparin and others (Goyal et al. 2017). In case of M, to prevent DVT in which blood clot occurs inside the body hindering blood flow to the site of the surgery and in the body, the thromboembolic prophylaxis medication is to be used.

Roles and Responsibilities of ODP for patient care

The role of Operating Department Practitioner (ODP) in patient care in surgery includes working in collaboration with multi-disciplinary operating team. They have the key aim to maintain and restore physical and psychological status of the patients in all level of the surgery as well as plan individual care for the patient (Harris and Nimmo, 2013). In anaesthetic phase, the ODP has the responsibility to check the identity of the patient and offer them individual care to prepare for the surgery (Harris and Nimmo, 2013). Thus, in case of M, the ODP has the role to assess M to inform her regarding laparoscopic cholecystectomy and make her feel psychologically as well as physically prepare to comply with the surgical process and provide informed consent for the surgery. This is because HCPC guidance informs those without the consent of the patient no care is to be provided and no forceful support is to be made to the patients by the healthcare professionals (HCPC, 2018).

In anaesthetic phase, the ODP has the role to arrange operating table and positioning of the patient for surgery. They also have the role to prepare the anaesthetic and intravenous equipment for the patients (Peate, 2019). This indicates that for M the ODP individual has the role to position her properly for laparoscopic cholecystectomy and manage anaesthetic along with intubation equipment. It is to ensure her effective breathing and health management during the surgical procedure as well as allow surgeon to perform the surgery without facing hindrance in locating the surgical site and operating. The WHO Surgical Checklist mention 19 questions to be asked by ODP to the patients before the surgery as it ensures safety and seen to lower chances of mortality by 30% (WHO, 2018). The WH checklist is used by OPD for M before he was provided aesthesia to ensure his safety during and after surgery.

In surgical phase, the ODP has the role and responsibility to ensure all surgical equipment for surgery is available for the surgeon and they are sterilised to avoid cross-infection. Moreover, they are to ensure the room temperature and airflow in the operation theatre is effectively maintained. They also are to ensure no retainment of surgical equipment is present inside the patient's body (Harris and Nimmo, 2013). Thus, for M, the OPD has the responsibility to ensure effective environment and room temperature along with airflow is created and sterilised equipment are used for laparoscopic cholecystectomy. They are required to ensure the ventilation is working effectively and safety guidelines are adequately maintained for providing general anaesthesia to M. In recovery phase, that is after the completion of surgery OPD has the responsibility to take patients out of the operating room, monitor them till they recover from anaesthesia, provide pain relief if require and decides whether the individual patient can be released from the ward (Peate, 2019). Thus, ODP in case of M has the responsibility to monitor her health till her recovery from anaesthetic state, check for infection and pain after surgery, assess for blood loss or breathing problem and decide her leave from the ward.

Roles and Responsibilities of ODP in relation to working with multi-disciplinary team

In order to remain effectively engaged with the multi-disciplinary team, the ODP service providers are to develop clarified and detailed communication of information for surgical procedure with the team. This is because clarified communication helps ODP during surgery to determine the need and demands of the multi-disciplinary team to ensure effective health management of the patients (Nordin et al. 2011). It is also evident from section 2 of the HCPC Code of Conduct also informs health professionals to communicate effectively with colleagues and team in care to ensure effective well-being of the patient (HCPC, 2018). This indicates that effective interaction between ODP and multi-disciplinary team in case of M would help them to determine the needs of surgical equipment and processes be fulfilled. It would lead to enhanced care to be offered to M in laparoscopic cholecystectomy surgery.

The development of trust and rapport is required for collaborative working by ODP with multi-disciplinary team in surgical environment. This is because it makes the ODP avoid involving into unnecessary conflict with multi-disciplinary team due to lack of trust and friendly relation (Zarog et al. 2018). The ODP team caring for M has the role to discuss and delineate roles with the multi-disciplinary team for effectively working with engagement in the surgical procedure of laparoscopic cholecystectomy. This is because delineation of role between ODP and team helps to avoid confusion regarding the responsibly to be played by each other in turn helping to avoid error or duplication in care (Abdelrahim et al. 2017).

Conclusion

The patient M is found to be suffering from cholecystitis for which laparoscopic cholecystectomy is to be performed as surgical process to elevate her issues with health. In the surgical process, the five steps of patient safety are followed along with risk assessment is performed by ODP for M. This is to determine the way care is to be performed and risks are to be managed. The ODP service providers by forming effective communication, building trust and delineating roles worked with multi-disciplinary team in the care procedure for M. The roles led ODP service providers to effectively perform perioperative care for M leading her to be safely transferred for care to the recovery staffs after surgery.

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