DEPARTMENT OF ANAESTHESIOLOGY

AND CRITICAL CARE

Kulliyyah Of Medicine
International Islamic University Malaysia (IIUM)

Case Write-up OT
Year 4 Block 1, 18/19

TITLE:
Controlled Ventilation General
Anaesthesia and Epidural Anaesthesia for
TAHBSO, Omentectomy and PLND

Name : Hannah Nahdia Mohammed Fauzi

Matric Number : 1516864
Group : C4
Supervisor : Asst. Prof. Dr. Suhaila Nanyan
IDENTIFICATION DATA

Name : Jariah Binti Awang

Age : 56 Years Old
Gender : Female
Race : Malay
Religion : Islam
Registration Number : 1023824
Identification Card Number : 620114115234
Occupation : Housewife
Address : Felda Endau, 86900 Endau, Johor.
Marital Status : Married
Status : Nulliparous
Last Menstrual Period : 13th August 2017
Ward : Obstetrics and Gynaecology Ward
Operation Done : Total Abdominal Hysterectomy Bilateral Salpingo-
oopherectomy (TAHBSO), Omentectomy, Pelvic Lymph Node Dissection (PLND) and
Appendicectomy
Type of Anaesthesia : Controlled Ventilation General Anaesthesia and
Epidural Anaesthesia
Date of Operation : 19/11/2018
CASE SUMMARY

My patient, Puan Jariah, a 56-year-old Malay lady, nulliparous, last menstrual period
was 8 months ago in March 2018, denied any perimenopausal symptoms; underwent a
total abdominal hysterectomy with bilateral salphingo-oopherectomy (TAHBSO),
omentectomy, pelvic lymph node dissection (PLND) and appendicectomy for huge right
ovarian tumor. She is a known case of hypertension, hyperlipidemia and
hyperthyroidism for more than 20 years under follow-up at Klinik Kesihatan Endau,
Johor.

She initially presented to the Obstetrics and Gynaecology clinic, IIUMMC on 9 th October
2018 with complaint of increased urinary frequency associated with a lower abdominal
mass for 2 months’ duration. She also complained of nocturia and occasional stress
incontinence. She denied any loss of weight or loss of appetite but claims she had early
satiety. She had no past surgical history. She also has no known drug or food allergy.

A CECT scan was done and revealed a solid ovarian tumour sizing 12x11x11cm, bowel
loops adjacent to it showed no obvious infiltration. Tumour markers AFP and CA-125
were normal but CEA was raised (57.9).

She was planned for debulking surgery on the 19 th of November 2018, which is today.
The surgery was done under general anaesthesia and epidural anaesthesia; it was
uneventful.
PREOPERATIVE ASSESSMENT AND MANAGEMENT

Pre-operative diagnosis: Ovarian Mass

Operation planned: Elective TAHBSO, omentectomy, PLND

My patient’s pre-operative assessment was done at the anaesthesiology clinic a week

prior to surgery (12/11/18) and was reviewed one day prior to surgery (18/11/18).
At the time, my patient was not pyretic, she had no upper respiratory tract infection
symptoms, no failure symptoms, no chest pain or palpitations, no dysphagia, no
shortness of breath or any compression symptoms. No hyperthyroidism symptoms.
However, she complained of increased urinary frequency. American Society of
Anesthesiologists (ASA) physical status classification was class II.

Physical Examination
 General : Alert, pink, no tremors, clinically euthyroid
 Cardiovascular : Dual rhythm no murmur
 Respiratory : Clear, equal air entry bilaterally
 Abdomen : Soft, non-tender, 18 weeks’ size solid mass
 Thyroid : Thyroid was not enlarged
 Spine : No abnormalities detected

Airway Assessment:
1. The maxillofacial anatomy is normal without any dysmorphisms.
2. Mallampati classification is class I.
3. She has good mouth opening, good neck extension and thyromental distance (TMD)
of more than three finger breadths.

Cardiovascular Assessment:
1. New York Heart Association (NYHA) class 1.
2. Metabolic equivalents (METs) score >4.

Vital signs:
 Blood pressure : 130/26mmHg
 Heart rate : 68 bpm

Preoperative Investigations:

Investigations Results

Full Blood Count Hb: 13.0 g/dL

WBC: 8x109/L
Platelets: 256 x 109/L

Coagulation Profile PT: 13.0s

aPTT: 31.5s
INR: 1.0
 Renal Profile Na: 139 mmol/L
K: 3.9 mmol/L
Urea: 3.6 mmol/L
Creatinine: 72 mmol/L
eGFR: 81

Liver Profile Albumin: 37

AST: 17 U/L
ALT: 13 U/L
ALP: 52 U/L
Total Bilirubin: 11

ECG Sinus rhythm, no ischemic changes

Chest X-ray No consolidations, no cardiomegaly, trachea not deviated.

Anaesthetic Plan
General anaesthesia and epidural anaesthesia

Special Order and Pre-anaesthetic Medication

1. To serve T. Carbimazole, T. Propanolol, T. Amlodipine (T. Perindopril if
BP>140/90)
2. Kept nil by mouth from solids for at least 6 hours and from clear fluids for at
least 2 hours with IVD maintenance.
3. Aspiration prophylaxis; IV Ranitidine, IV Metoclopramide, Na Citrate
4. Invasive monitoring
5. ICU back-up (anticipate prolonged operation)
6. PT/APTT/INR in ward
7. GXM 4 pints packed cell to OT
8. No need premedication
9. Anaest review 1 day before operation

INTRAOPERATIVE MANAGEMENT

Pre-operative Diagnosis: Ovarian Tumour

Post-operative Diagnosis: Right Mucinous? Ovarian Tumour (Stage 1C, HPE Pending)
Surgery: Total abdominal hysterectomy bilateral salpingoopherectomy (TAHBSO),
omentectomy, pelvic lymph node dissection and appendicectomy.

Prior to surgery, Puan Jariah firstly underwent epidural anaesthesia in a sitting position.
An 18G epidural needle was inserted at level L3/L4 in a midline approach. The epidural
catheter was anchored at 9cm in a single attempt without any complications.
She had a 18G branula on her left dorsal hand from the ward. In the OT, another 18G
branula was inserted at her right dorsal hand and a third line was inserted at her right
external jugular vein using a 16G branula.
Then, my patient underwent general anesthesia. She was preoxygenated for about 3
minutes and was then induced with:
i. IV Fentanyl 100mcg
ii. IV Propofol 120mg
iii. IV Rocurorium 50mg
My patient was intubated with an endotracheal tube of size 7.5mm and anchored at
18cm in a single attempt which was uneventful.
Anaesthesia was maintained with Sevoflurane MAC 0.9-1.1. Boluses of IV rocurorium
10mg were given a total of 5 times. Analgesics given were:
i. Epidural Chirocaine 0.25% - 2-3ml boluses
ii. Epidural Chirocaine 0.1% + Fentanyl 2mcg/ml
iii. IV Fentanyl 25mcg
iv. IV Paracetamol 1g
v. IV Parecoxib
Other medications given were IV Augmentin 1.2g, IV Granisetron 1mg, IV Parecoxib
40mg and IV Neostigmine for reversal.

Monitoring:
 BP: 130-110/80-60 mmHg
 HR: 50-70 bpm
 Not requiring any inotropes intra-operatively
 Cardiac monitoring: sinus rhythm
 Tempature: 35.6-36.8 oC
 EtCO2: 35-38 mmHg

Fluid Loss: From cyst 1.5L, EBL 500mls, Urine 250mls

Fluids administered: 250mls Normal Saline (from ward), 550mls Hartmann’s Solution,
1 pint Normal Saline (Total = 7691mls)

POST-OPERATIVE MANAGEMENT

- Vital sign monitoring quarter hourly x2, half hourly x2, hourly x2, 2 hourly x2
then 4 hourly if stable
- To continue epidural infusion in ward: Chirocaine 0.1% + Fentanyl 2mcg/ml
- APS review
- Allow orally once fully conscious
DISCUSSION

The three main points I would like to discuss are:

1. Anaesthesia in Patients with Thyroid Disease
2. Post-operative Nausea and Vomiting (PONV)
3. Post-operative Pain Management

Anaesthesia in Patients with Thyroid Disease

My patient, Puan Jariah is a known case of hyperthyroidism. She was diagnosed with
hyperthyroidism for more than 20 years and is under follow-up at Klinik Kesihatan
Endau.
It is important to carry out a thorough pre-operative assessment in patients with
hyperthyroidism. A few of the reasons being
- If the patient has enlarged thyroid gland or goiter, it would indicate difficulty in
intubation
- If patient is clinically hyperthyroid, drugs should be administered until patient is
euthyroid to avoid further complications such as thyroid storm

Based on the Oxford Handbook of Anaesthesia, below are the general considerations for
patients with thyroid disease in non-thyroid surgery.
Hypothyroidism
- Commonly due to autoimmune thyroid destruction.
- The CVS complications of hypothyroidism include decreased blood volume,
cardiac output, and heart rate, with a predisposition to hypotension and ischemic
heart disease (IHD). Pericardial effusions may also occur.
- It is also associated with anaemia, hypoglycaemia, hyponatraemia, and impaired
hepatic drug metabolism.
- If patient is found to be clinically hypothyroid, delay elective surgery to obtain a
euthyroid state. Liaise with the endocrinologist. Suggest levothyroxine (T4)
(starting dose Tab. 50mcg, increasing to 100–200mcg over several weeks).
Those who are elderly are more susceptible to angina and heart failure, with
increasing cardiac work caused by thyroxine, so start with 2mcg, and increase by
25mcg at 3- to 4-weekly intervals.
- If surgery is urgent, then liothyronine (T3) (10–50mcg slow IV with ECG
monitoring, or 5–20mcg in patients with known or suspected cardiac disease,
followed by 10–25mcg 8-hourly) can be used, but this is more controversial.
Hyperthyroidism (thyrotoxicosis)
- Patients who are clinically hyperthyroid typically presents with weight loss,
hypertension, sweating, and cardiac arrhythmias (especially atrial fibrillation).
Treatment is with carbimazole (30–45mg PO daily for 6–8wk). This inhibits
iodination of tyrosyl residues in thyroglobulin. Occasionally, in severe cases with
a large thyroid, Lugol’s iodine is substituted 10d preoperatively to reduce gland
vascularity.
- β-blockers (propranolol 30–60mg tds) are also started if there are signs of
tremor or palpitations. The non-cardioselective β-blockers, such as propranolol,
are more effective than the selective ones. β1-adrenergic blockade treats the
symptoms of tachycardia, but β2-adrenergic blockade prevents the peripheral
conversion of T4 to T3.

The preoperative assessments that should be done in patients with thyroid disease
include assessment of thyroid function, ensure that the patient is euthyroid; heart rate
less than 80 beats per minute and no hand tremors— surgery should be delayed, if
possible, until euthyroid state is achieved. However, patients with subclinical
hypothyroidism usually have no anaesthetic problems, and elective surgery can proceed
without special preparations. A proper airway assessment and respiratory examination
should also be carried out to look for tracheal deviation—a large goitre can cause
respiratory obstruction particularly when the enlargement extends retrosternally. The
patient should be inquired about positional dyspnoea and dysphagia. Look for evidence
of tracheal compression with shortness of breath, dysphagia, and stridor (occurs with
50% compression). Infiltrating carcinoma may make any neck movement difficult and is
an independent predictor of difficult intubation.
My patient however, did not have any active hyperthyroid symptoms; she is clinically
euthyroid. On examination, there was no thyroid enlargement or tracheal deviation.
Mallampati classification showed class I, good mouth opening and neck movement.
Additional investigation for thyroid function should also be taken to confirm any hyper-
or hypothyroidism. My patient’s thyroid function tests showed T4 - 12.29 which is
normal and TSH <0.005 which is low.
As for the conduct of anaesthesia in hypothyroid patients, anaesthetic drugs should be
administered slowly as patient is susceptible to profound hypotension, which may be
relatively resistant to the effects of catecholamine therapy. Their low metabolic rate
also predisposes to hypothermia, so actively warm the patient by giving warm IV
infusions, covering patient with a warming blanket. Controlled ventilation is
recommended because patients have the tendency to hypoventilate.In hyperthyroid
patients, β-blockers should be continued perioperatively to reduce the possibility of a
thyroid storm. My patient did not require any specific management as she is in
euthyroid state.
Post-operative Nausea and Vomiting (PONV)
Post-operative nausea and vomiting (PONV) can be one of the most distressing parts of
a surgical journey. It affects approximately 20-30% of patients within the first 24-48
hours post-surgery. Post-operative nausea and vomiting are uncomfortable for patients,
can prolong hospitalization, and can lead to more serious complications, including
aspiration pneumonia. Accurately predicting which patients are at risk of postoperative
nausea and vomiting can help physicians decide when to recommend prophylactic anti-
emetics. 
There are a number of risk factors for PONV. These risk factors can be further divided
into patient factors, surgical factors, and anaesthetic factors.

Patient Factors Surgical Factors Anaesthetic Factors

 Female  Intra-abdominal  Opiate analgesia or

laparoscopic surgery spinal anaesthesia
 Previous PONV or
motion sickness  Intracranial or middle  Inhalational agents
ear surgery (e.g. Isoflurane,
 Use of opioid nitrous oxide
analgesics  Squint surgery
(highest incidence of  Prolonged
 Non-smoker PONV in children) anaesthetic time

 Gynaecological  Intraoperative
surgery, especially dehydration or
ovarian bleeding

 Prolonged operative  Overuse of bag and

times mask ventilation
(due to gastric
 Poor pain control dilatation)
post-operatively

Females have a higher incidence of PONV than males and those of reproductive age
suffer up to three times more often with PONV than men. This suggests that PONV is
aggravated by a hormonal influence. Patients who have a history of motion sickness or
previous PONV can have a well-developed reflex arc for vomiting hence they are at an
increased risk of PONV. Opioids contribute to PONV via stimulation of the
chemoreceptor trigger zone (CTZ). The type of surgery influences the incidence of
PONV. Intra-abdominal surgery, ophthalmic surgery (particularly for strabismus),
gynaecological surgery and middle ear surgery are all associated with higher rates of
PONV.
The high incidence of PONV following an open abdominal or intra-abdominal
laparoscopic surgery may be due to gut ischaemia releasing 5HT. It has been suggested
that the longer the surgery the greater the incidence of PONV, possibly due to post-
operative ileus which is associated with extensive bowel handling during surgery and
bowel wall oedema in longer procedures.

The anaesthetic induction agent etomidate is associated with an increase in PONV

compared with thiopentone or propofol. Of the volatile inhaled anaesthetic agents,
sevoflurane and desflurane are reported to be associated with lower rates of PONV than
enflurane or halothane. Nitrous oxide increases the incidence of PONV. It affects central
opioid receptors, causes changes in middle ear pressure and causes bowel distention.
The use of intubation is thought to increase risk of PONV because of pharyngeal
mechanoreceptor afferent stimulation. Peripheral nerve blocks, total intravenous
anaesthetic (TIVA) techniques and regional anaesthesia are all associated with a lower
incidence of PONV than general anaesthesia with intubation and a traditional volatile
agent dependent anaesthetic technique. Gastric inflation during mask ventilation can
cause PONV because gaseous distention of the stomach and upper small intestine
activates mechanoreceptors, sending afferent signals via the vagus nerve.
The risk factors present in my patient are female, use of opioid analgesics, non-smoker,
open abdominal surgery, prolonged surgery, use of opiate analgesia and also use of
inhalational agents. There are several predictive scores for PONV. Two of which are the
Apfel score and also the Koivuranta score. The Apfel score includes four variables and
assigns one point for each while the Koivuranta score includes five variables which are
similar to the Apfel score but adds prolonged surgery (lasting more than 60 minutes)
and also assigns one point for each. Both scores were shown to validate well in several
studies and performed similarly in the validation studies. Below shows the Apfel score.

Apfel Score

Characteristics Points

Female 1

History of motion sickness and PONV 1

Non-smoker 1

Post-operative opioid is planned 1

Risk Score Prevalence PONV Examples of Drugs Given

0 9% ± Ondansetron 4 mg
1 20% Ondansetron 4 mg
± Dexamethasone 4mg
2 39% Ondansetron 4 mg
+Dexamethasone 4mg
± Propofol infusion
 3 60% Ondansetron 4 mg
+ Dexamethasone 4 mg
+ Propofol infusion
± Scopolamine patch
4 78% Ondansetron 4 mg
+ Dexamethasone 4 mg
+ Propofol infusion
+ Scopolamine patch

Other than the above recommended treatment, we should also consider strategies to
reduce PONV baseline risk such as regional anesthesia instead of general anesthesia,
adequate hydration, propofol for induction and maintenance; minimize the use of
nitrous oxide and volatile anesthetics.
Based on the above shown Apfel scoring, my patient’s total score would be 3; female,
non-smoker and planned for post-operative opioid indicating a 60% risk for PONV. The
recommended treatment for Apfel 3 is Ondansetron, Dexamethasone, Propofol with or
without Scopolamine. However, instead of Ondansetron, my patient was given
Granisetron.
A study was carried out to compare Ondansetron and Granisetron in prevention of
PONV. There are a number of drugs that are used to manage PONV. These drugs are
generally anti-histaminics, phenothiazine derivatives, anticholinergics and dopamine
receptor antagonists with unwanted side effects like sedation, dysphoria, reversible
extrapyramidal symptoms, dry mouth, restlessness and tachycardia. Recently
introduced 5HT3 receptor antagonists are devoid of such side effects and highly
effective in prevention and treatment of PONV. The commonly used drug is
Ondansetron; 4 mg intravenously is the effective dose to prevent PONV. Recently
introduced another 5HT3 receptor antagonist Granisetron which has a more potent and
longer acting activity than Ondansetron.

Post-operative Pain Management

Total abdominal hysterectomy and bilateral salpingo -oophorectomy (TAHBSO) is a
surgical procedure frequently associated with severe or moderate postoperative pain.
Total abdominal hysterectomy and bilateral salpingo -oophorectomy is the procedure in
which the doctor removes the uterus, including the cervix, both ovaries and fallopian
tubes. The fast recovery depends on minimizing the postoperative symptoms, especially
pain.
My patient undergone epidural anaesthesia which was continued until 3 days post-
operatively. Listed below are the advantages of epidural anaesthesia:
1. Pain relief
When indicated, epidural analgesia is the best choice for postoperative pain
relief. It can be administered for all types of surgery of the chest, abdomen and
legs, but not the neck, arms or head. The latter would involve an epidural effect
 that reaches too high up, making it impossible to breathe or maintain a normal
blood pressure and heart rate. Since the local anaesthetic in the epidural space
blocks the nerves where they enter (and leave) the spinal cord, all pain and
sensation can be taken away, even while you move or cough.
It differs from morphine and other painkillers that are administered systemically
(i.e. orally, intravenously, intramuscularly or rectally – they go to the “whole
system”) in that systemically administered painkillers can never completely
relieve pain. Pain receptors in the brain and tissues are blocked, but not the
action of the nerves that conduct the pain impulse to the spinal cord and brain.
With systemic painkillers, you are rarely pain free in the physiotherapy,
movement and coughing can still be painful.

2. Easier breathing
Because the pain relief is so complete, breathing and coughing are completely or
almost completely free of pain. This allows for better expansion of the lungs,
better uptake of oxygen, and better coughing up of secretions, which is especially
important for smokers. Overall, it leads to a decreased risk of pneumonia.

3. Less stress on the heart

Pain increases heart rate and blood pressure, which can be harmful to patients
with a poor heart and even cause a heart attack. Perfect pain relief with an
epidural can therefore decrease the risk of cardiac complications after an
operation.

4. Earlier feeding
The local anaesthetic in the epidural infusion improves bowel contraction.
Systemically administered morphine (via intravenous or intramuscular
injection) paralyses the bowel, and this can be avoided almost completely if
epidural pain relief is used. It allows patients to start eating the day after
surgery, even after abdominal operations (i.e. surgery on the intestines).

5. Decreased risk of deep venous thrombosis (DVT)

Major surgery, and especially orthopaedic surgery, predisposes one to the
formation of blood clots in the legs or pelvis, which can shoot up to the lungs and
be fatal. Epidural analgesia decreases the risk for this complication by 30
percent.

6. Decrease in general stress response

Surgery subjects your body to a lot of stress – not the stress of daily life, such as
sitting in traffic jams or living at a hectic pace, but physiological stress: pain,
cooling during surgery, blood loss, etc. If all these stressing factors are treated
appropriately, the challenge (“stress”) to the body will be much less, allowing for
a speedier and less complicated recovery. For example: the stress of pain
increases your heart rate and blood pressure, and in a person with heart disease,
this can lead to a heart attack.
Other post-operative pain management options include Patient Controlled Analgesia
(PCA) which will not be discussed here.
REFLECTION ON ETHICS AND ISSUES OF PROFESSIONALISM

When making decisions regarding patient care, the anaesthesiologist, as the provider of
medical care, should demonstrate respect and honesty for the patient. The ethical
practice of anaesthesiology is based on the following guiding principles:
1. Non-maleficence—Anaesthesiologists abide by the doctrine of “do no harm” to
their patients. However, sometimes a treatment, such as providing general
anaesthesia for an operation, can unintentionally lead to harm, such as cardiac
arrest due to hypoxemia, when the intention was for good. Successful application
of this principle may be difficult.
2. Autonomy—The patient is an independent being who can make fully informed
decisions regarding his or her own health care. They have the right to accept or
refuse diagnostic or therapeutic interventions. A full informed consent is
necessary for the competent patient to understand risks and benefits, and to
achieve autonomy. Coercion is unethical, even if the patient’s decision may not
be in his or her best medical interest.
3. Justice—Anaesthesiologists should be fair when providing their services to
surgical patients. All members of society deserve to receive medical resources,
no matter how scarce. When considering the principle of justice, physicians
should evaluate a patient’s legal rights as well as possible conflicts with local
laws.
4. Beneficence—While the principle of non-maleficence is based on “do no harm,”
beneficence requires physicians to “do good” for the patient in every situation.
Anaesthesiologists should evaluate each patient’s individual situation and not
apply the same blanket decision for everyone. To do so, physicians must
maintain their skills and update their medical knowledge on a regular basis.

“Worship Allah and associate nothing with Him, and to parents do good, and to
relatives, orphans, the needy, the near neighbor, the neighbor farther away, the
companion at your side, the traveler, and those whom your right hands possess. Indeed,
Allah does not like those who are self-deluding and boastful.”
– Quran 4:36

This is a direct command, an order to be good and kind to other human beings. The
present verse emphasises and orders Muslims to be kind and do good to their parents,
relatives, orphans, the needy, their neighbour(s), their wife, a traveller, captives of war
who were in their possession and others. As Muslims in a noble profession, one should
always be kind and ethical towards others.
REFERENCES

1. Essentials Anesthesiology for Healthcare Professionals, 2nd Edition, 2012

2. Oxford Handbook of Anaesthesiology, 4th Edition, 2016
3. Post-operative Nausea and Vomiting, The Pharmaceutical Journal
4. The Holy Qur’an