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Partial Nephrectomyfor Renal Cell CarcinomaCase Study:BEST PRACTICES IN HEALTHCAREMAKAILA BRANCH, CER. A.T.T.OKLAHOMA CITY COMMUNITY COLLEGEPatient PresentationA 60-year-old female patient presented to the operatingroom with renal cell carcinoma. The proposed surgerywas a left open partial nephrectomy. The medical historynoted allergies to penicillin and prochlorperazine. Theanesthesia care team (ACT) quantified the patient as anASA III. Her height was 67in. and she weighed 94.8kg.She was positioned in right lateral decubitus for thesurgery. During the respiratory review, the ACT notedthe patient was a smoker with COPD and concomitantallergic rhinitis. Her cardiovascular review noted ahistory of hypertension. Her central nervous systemrevealed anxiety and headaches. During the hepatic,renal, and gastrointestinal review, the ACT noted severalpathological conditions, including urinary incontinence,liver metastases, and chronic nausea. The finalpathophysiology analysis noted the patient was obeseand did not have teeth. The patient's prior anesthetichistory was extensive, an embolization of a basilar arteryaneurysm, hysterectomy, cholecystectomy, and a D&Cprocedure. Basilar artery aneurysms The patient had nottaken any medication the day of surgery.MORESensor Spring 2021The
BEST PRACTICES IN HEALTHCARECONTINUING FROM PREVIOUS PAGESurgical BackgroundRenal cell carcinoma is a common etiology for a patientrequiring a partial nephrectomy. According to Jaffe'sThe Anesiologists Manual of Surgical Procedures, partialnephrectomies are ideal for small cell carcinomas."Partial nephrectomy is the surgical excision of thesegment of the kidney harboring the pathology. It isperformed for small renal cell carcinomas and benigntumors of the kidney, such as angiomyolipomas, and forduplicated collecting systems with a diseased moiety(Jaffe, 2014, p. 892-893)."Given the patient's history, there were surgical implicationsthe anesthesia technologist should be aware of in order tobest assist the anesthesia provider in caring for the patient.One special consideration was needed to for the patient'sCOPD. Patients with COPD will have increased compliancedue to the destruction of elastic recoil in the in alveoli. Pardoand Miller in the Basics of Anesthesia 7th edition recommendpreoperative bronchodilator therapy to counteract theobstructive disorder.and bronchodilator breathing treatments, Pardo and Millerindicate that preoperative chest physiotherapy is noted toreduce pulmonary complications post-surgical intervention.(Prado and Miller, 2018, p. 466). Chest physiotherapy is amanual process of clearing mucous from the respiratorysystem. It relies on percussive measures being applied todifferent areas of the chest wall. The goal is to move thesecretions to the patient's midline. The process also includes"All patients with COPD should receive bronchodilatortherapy as guided by their symptoms. If sympathomimeticand anticholinergic bronchodilatorsprovide inadequatetherapy, a trial of corticosteroid therapy should begetting the patient to produce solid coughs to remove therepositioned secretions.Before the start of the case, the anesthesia technologistshould make sure suction is on the anesthesia machine,instituted (Pardo and Miller, 2018, p. 466)."working effectively, and generating 40.6kPa (Dorsch, 2012).In addition to the standard yankaur used for oropharyngealsuctioning during induction, the technologist should ensurethe anesthesia deck has appropriately sized tracheal suctioncatheters. A patient with COPD is likely to have moresecretions upon emergence, and the anesthesia provider willneed the suction ready to go to ease the emergence process.Another anesthetic consideration specific to this patientdealt with her medication history. The patient was onchronic lisinopril, which could affect her drug metabolismdue to her liver metastases. Lisinopril is a class of ACEinhibitor used as a vasodilator. In combination with thepatients Liver metastases, the anesthesia care team shouldreduce hepatic and renal metabolized medications. For thisreason, the patient was given Cisatracurium besilate forNeuromuscular blockade since this NMBA relies on Hoffmannelimination as opposed to hepatic and renal metabolismConcerning the alveoli, the pre-surgical breathing treatmentcommonly associated with Rocuronium Bromide.can help open the alveolar walls and decrease secretions. AThe technologist needs to have a fluid warmer setup anddrug that is typically used to reduce secretions from COPDready to use to compensate for evaporative heat loss due tois glycopyrrolate. In addition to the anticholinergic agentsthe patient having open abdominal surgery. DueSensorTheMORESpring 2021
BEST PRACTICES IN HEALTHCARECONTINUING FROM PREVIOUS PAGEto the patients' comorbidities, the provider requestedhead (Pardo and Miller, 2018, p. 325). During positioning,an ultrasound in the room to assist with the arterial linespecific attention was given to the patient's extremities toplacement.prevent nerve damage. The dependent arm (in this case,the right arm) was placed in an arm board cushioned withPatient Positioningfoam padding. The non-dependent arm was folded over theProper positioning is imperative for patient safety. A partialdependent arm and placed in an attachable armrest withnephrectomy is a 3-4-hour procedure, so appropriateadditional padding.positioning precautions were taken to prevent injury andnerve neuropathy. As stated earlier, the patient was in thelateral decubitus position for the surgery. A prone pillowwas used to keep the spine in a neutral position. Anotherconsideration taken during the positioning was making surethe patient's dependent ear was not compressed and theeyes were taped and free from pressure. It is important tonote that the dependent ear and eye, or the eye and ear inclosest contact to the OR table, should be routinely checked.The ear should be free from bending as this can potentiatelocalized ischemia. Additionally, the dependent eye is moreprone to increased intraocular pressure (IOP). According tothe American Academy of Ophthalmology, signs of increasedIOP are forward displacement of the lens, corneal edema,irregular pupils, and mid-dilated pupils, among other clinicalsigns. Pharmacologically, the Seventh Edition of Miller'sAnesthesia recommends avoiding ketamine and nitrous oxidewhen IOP increases are predicted. The text does recommendusing volatile anesthetics and opioids as these are shown toreduce IOP (Miller, RD et al., 2009).An axillary roll was placed just below the axilla to preventdamage to the Axillary nerve. The axillary roll was placedbelow the axilla rather than directly in the axilla to avoidcompression against the axillary nerve, which wouldThe positioning of the extremities is important when in thepotentiate damage to the brachial plexus. Additionally, itlateral decubitus position. Injuries to the Brachial Plexusshould be noted that the axillary roll's placement belowand Common Peroneal nerve are the most common unlessthe axilla helps reduce suprascapular nerve damage (Pardopreventive measures are taken. According to Miller andand Miller, 2018, p. 325). A pillow was placed underneathPardo's Basics of Anesthesia, injury to the brachial plexusthe patient's hips to protect the bony prominences andis avoided when the arms are not abducted more than 90avoid damage to the sciatic nerve. According to Prado anddegrees, and proper padding is used to prevent compressionMiller (2018), special considerations should be taken wheninjuries to the Brachial Plexus induced by the humeralpositioning the lower extremities as well.SensorTheMORESpring 2021
BEST PRACTICES IN HEALTHCARECONTINUING FROM PREVIOUS PAGE"The dependent leg should be somewhat flexed. A pillowline was free of kinks and zeroed at the phlebostatic axis. Ifor other padding is generally placed between the kneesthe patient still had the basilar artery aneurysm, the arterialwith the dependent leg flexed to minimize excessiveline would need to be zeroed at her ear to give a morepressure on bony prominences and stretch of loweraccurate reading of the pressure in the head. However, sinceextremity nerves (Prado and Miller, 2018, p. 325)."her basilar artery aneurysm was managed in a previousTo protect the patient's lower extremities, the dependentleg (right leg) was slightly flexed with padding underneathto protect the Common Peroneal nerve. A pillow was placedbetween the patient's knees to protect the popliteal nervefrom injury. The non-dependent leg (left leg) was slightlyextended and placed over the pillow on the dependentleg. Padding was placed under the dependent foot's heeland between the patient's ankles for further neuropathyprevention.surgery, the arterial line was zeroed at the phlebostatic axis.Prior to the start of the case, the anesthesia technologistprovided an ISTAT to have on hand for intraoperative bloodtesting. Blood administration was not necessary during thiscase. However, depending on the amount of blood loss, apartial nephrectomy could require blood administration. ASAmonitors are required with every surgery. This patient wasconnected to a pulse oximeter, non-invasive blood pressurecuff, EKG leads, and a temperature probe, all of which hadno artifacts or intraoperative anomalies. A foley catheterInduction Sequencewas placed to monitor urine output and assess fluid needs.It is essential to be prepared and have the correct equipmentfor induction. If the anesthesia technologist is familiar withthe anesthesia provider's preferred setup, the anesthesiatechnologist should have the induction equipment set upbefore starting the case. For this case, the resident used aMAC 3 laryngoscope blade, 7.0 endotracheal tube, and a 9cmBerman oropharyngeal airway. According to Jaffe (2014), thisprocedure can be associated with higher fluid requirements(8-10 mL/kg/h). Normal saline or lactated ringers should begiven at 6-8 mL/kg/h, and all fluids should be warmed. Mildto-moderate blood loss can be expected (Jaffe, 2014, p. 898).For this procedure, the patient had a 20-gauge macro drip IVin her left arm and an 18-gauge hotline with normal saline inher right arm.According to Jaffe (2014), regional techniques such as aspinal or epidural may be combined with general anesthesiato minimize postoperative pain (Jaffe, 2014, p. 898). Thepatient, in this case, had an epidural placed preoperativelyto aid in pain management. Upon successful extubation, thepatient was taken to the PACU in a simple face mask withauxillary oxygen at 8L/min. Once the patient was moved tothe floor, a PCA was administered to help with postoperativepain management.ComplicationsComplications with this procedure include pneumothoraxand decreased blood pressure due to the lateral position(Jaffe, 2014, p.898). Because the patient had COPD, she wasat a higher risk for complications such as pneumothorax,An arterial line was placed in the patient's right radial arteryfor invasive blood pressure monitoring. The requirement ofthe arterial line was two-fold. The severity of the surgery andrisk of acute hypotension and the intraoperative monitoringand management of the patient's hypertension. The arterialatelectasis, and pneumonia. To prevent a pneumothoraxor further complications with the patient's COPD, theendotracheal tube was taped securely and was monitoredperiodically to ensure negative tube migration and negativeright bronchial mainstem lung isolation. At the start of thecase, the resident had difficulty placing the arterial line. Shefirst attempted to place the arterial line in the left radialartery before the patient was moved to the lateral decubitusposition. However, she was unable to locate the artery,and the surgeon wanted to begin the procedure. After thepatient was placed in the right lateral decubitus, the residentattempted to place the arterial line in the right radial arteryunder the sterile drapes. She could not locate the right radialartery as well, so the anesthesia technologist brought inan ultrasound. The ultrasound enabled the resident to geta better view of the artery, and she was able to place thearterial line.SensorTheMORESpring 2021
BEST PRACTICES IN HEALTHCARECONTINUING FROM PREVIOUS PAGEConclusionIn conclusion, a 60-year-old female with renal cell carcinomawas scheduled for a left open partial nephrectomy. Thepatient was placed in the right lateral decubitus position,which requires special attention to extremity placementand nerve padding. Several implications and considerationswere to be taken with the patient's prior conditions, such ashypertension and COPD. Due to the preoperative concernsassociated with this type of procedure, an anesthesiatechnologist must be familiar with the case and anticipatethe anesthesia provider's needs by attaining a baseunderstanding of renal physiology and pathophysiology.The anesthesia technologist played an important rolein providing the best possible care for the patient. Thetechnologist assisted with the patient's preoperativerespiratory bronchodilation treatment, anesthesia roompreparation according to best practice found in literature andprovider preference, safe induction, and emergence fromanesthesia, and safe transport to the PACU. The patient'ssurgery was successful with an ideal margin removal ofcancer and was completed in 210 minutes. The patient wasextubated after exiting Guedel Stage-Two of anesthesia tolimit the possibility of laryngospasm. Upon extubation, thepatient was given supplemental oxygen at 8L/min. via simplefacemask and transported to PACU for continued monitoringand evaluation.ReferencesJaffe, R. A., Schmiesing, C. A., & Golianu, B. (2014). Anesthesiologistsmanual of surgical procedures (5th ed.). Philadelphia, PA: WoltersKluwer.Pardo, M. C., & Miller, R. D. (2018). Basics of anesthesia (7th ed.).Philadelphia, PA: Elsevier.SensorTheQUIZTake theOn The Next PageSpring 2021
SensorTheBEST PRACTICES IN HEALTHCARESpring 2021Continuing Education QuizTo test your knowledge on this issue’s article, provide correct answers to the followingquestions on the form below. Follow the instructions carefully.1. What is the common etiology for a patientrequiring a partial nephrectomy?6. All are signs of increased intraocularpressure except?2. What can be given to a patient Ifsympathomimetic and anticholinergicbronchodilators are not adequate treatmentsfor their COPD?7. What is the most common nerve injury fora patient in a lateral decubitus position?a. Angioedemab. Renal Cell Carcinomac. Sickle-Cell Diseased. Pheochromocytomaa. Trial corticosteroid therapyb. Looped-diuretic treatmentc. Inotropic infusion therapyd. Beta-blocking agonist treatment3. What is lisinopril?a. Beta blockerb. Bronchodilatorc. Vasopressord. ACE inhibitor4. Why type of metabolization doesCisatracurium rely on?a. Hepatic metabolizationb. Renal eliminationc. Hoffmann eliminationd. Pancreatic metabolization5. What should be checked routinely for patientsin a lateral decubitus position?a. Dependent eyeb. Non-dependent eyec. Jugular distentiond. Intercostal neuropathyTo apply for Continuing Education/Contact Hours:1) Provide all the information requested on this form.2) Provide correct answers to this issue’s quiz in this box 3) Mail this form along with 10.00 Member 20 Non-Member(check or money order, payable to ASATT) to:"ASATT", 7044 S 13th St, Oak Creek, WI 53154a. Corneal crenationb. Forward displacement of the lensc. Mid-dilated pupilsd. Irregular pupilsa. Trigeminal nerveb. Glossopharyngeal nervec. Common peroneal nerved. Femoral nerve8. What is a known complication associatedwith this procedure?a. Pneumothoraxb. Pneumoplastyc. Cranial decompressiond. Cardiac tamponade9. Arterial lines should be zeroed to thephlebostatic axis on patients with untreatedbasilar artery aneurysms.a. Trueb. False10. What is the name of the manual processfor clearing mucous in the respiratory systemcommon with COPD patients?a. Chest physiotherapyb. Spinal physiotherapyc. Peroneal physiotherapyd. Intercostal physiotherapyThe answers tothe Spring 2021"Partial Nephrectomyfor Renal CellCarcinoma"Quiz are:(circle answers)1: A B C D6: A B C D2: A B C D7: A B C D3: A B C D8: A B C D4: A B C D9: A B5: A B C D10: A B C DQuiz 2 of 2Name: ASATT Number: Street Address: Phone Number: City: State:Zip: Signature: Date: SUBMISSIONS FOR THIS ISSUE’S QUIZ EXPIRE DECEMBER 31, 2022.ACHIEVE 80% IN THIS QUIZ TO EARN ONE (1) CONTINUING EDUCATION CREDIT.576 577
According to Jaffe (2014), regional techniques such as a spinal or epidural may be combined with general anesthesia to minimize postoperative pain (Jaffe, 2014, p. 898). The patient, in this case, had an epidural placed preoperatively to aid in pain management. Upon successful extubation, the
