ODN Conference Proceedings 2019

INMO Operating Department Nurses Conference took place on Saturday 30.11.19 - theme "Together Towards Tomorrow".

Operating Department Nurses Section Conference

‘Together Towards Tomorrow’

CONFERENCE PROCEEDINGS

Saturday 30 November 2019

30/11/2019

The initial call comes from Mr. Russell / Ms Mehanna, we have an Exit procedure.

Nursing Team

• The highly skilled nursing team consists of • Scrub and circulating nurse,

Coordination of Exit Procedure

Date and time for MDT is set up.

CNM 1 and CNM 2 • Anaesthetic nurse • Airway CNS

Then I coordinate the nursing team and clinical engineering, ensuring all are rostered on duty on the day of the planned exit .

ContactCNM3 in thematernityhospital.

Equipment is sent twodayspre‐op for sterilisation

MEETEARLY

CHECKALLEQUIPMENTREADY THATMUSTBEBROUGHTON THEDAY

Important to check things, suchasbi‐polar.

Day of the procedure

Pre‐ procedure

Logisticsofmoving team,organise transport.

InsureENT theatre is leftavailableandon standby.

Meetwithnursing teamandgo through checklist.

Bookan ICUbed.

ENTTHEATRETOBEKEPTFREE

CONFIRM ICUBED

Reflection

• April 2018, first exit in 8 years. • Preference sheet and checklist complied. • PPE • December 2018… what we did differently • Team brief, consultant from each team outlined their role and expectations. • Name badges. • Noise and crowd control.

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Ex‐utero intrapartum treatment

Nursing Considerations

Roisin Mullan Clinical Nurse Specialist Paediatric Airway Management

Involvement from the beginning.

• The airway CNS will meet with the ENT surgeon and they will discuss the diagnosis of the baby. • After it is decided to proceed with an EXIT procedure the planning begins for the multi‐disciplinary team across the paediatric and maternity hospitals.

• Introduction to the parents. • Beginning of preparation of the parents of the EXIT procedure. • Here discussed are the many possibilities for the baby on delivery.

The first meeting of the parents with the ENT surgeon and CNS • The ENT surgeon will explain the results and diagnosis from the babys scan. • They are counselled about EXIT procedure and the risks associated with it. • They are informed that it is highly likely a tracheostomy will be performed on the baby at the time of birth ( the EXIT procedure). • Naturally the parents have many questions here and they need time to process the information they have been given. • So we arrange a second meeting.

The second meeting with the parents. • The next meeting of the parents with the CNS and ENT surgeon is usually in Crumlin hospital • The CNS will bring a manikin doll with a tracheostomy tube insitu.

• The CNS gives the mam and dad a walk through of the hospital. • Also answer any questions they have.

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Suction Machine and Trachi‐Case

• The medical and nursing staff from Crumlin get ready days in advance. They leave early in the morning and travel to the maternity hospital, and set up in the theatre.

• The CNS has to bring several neonatal and paediatric tracheostomy tubes of various sizes, including cuffed and uncuffed tubes.

• An emergency trachi‐case is also brought as this will be needed for the transfer of the baby.

Immediately after the EXIT

• In Crumlin Childrens Hospital approx 12 new tracheostomies are performed every year. • What for ? • Upper airway obstructions, as in this case. • To facilitate ventilation on a baby who has chronic lung disease or tracheo/bronchomalacia. • Approx 10 removal of tracheostomy (decannulation) every year.

• The Neonatal team will intervene and stabilise the baby. • The ENT surgeon and CNS will usually meet the dad after the baby is born and discuss with them the outcome. • The baby is transferred in an ambulance to the intensive care in Crumlin. • The dad is met at Crumlin Hospital and brought to ICU.

Tracheostomy tubes – specialised nursing care • Children who have tracheostomy, have single lumen tubes.

Ireland – approx 50 – 60 children with Tracheostomy • How are they different to adults with tracheostomy?

• Their trachea is small so there is no room an inner cannula.

• They can’t look after it themselves. • Its much smaller tube – more potential to block with secrections. • They can pull it out themselves or their Brother/sister can pull it out for them 

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Next steps…

Time for discharge planning • Now that the baby is stable and has a secure airway with their tracheostomy, they can move out of the intensive care and to the ward. • Parent education continues and a nursing home care package is applied for. • After usually 3 – 4 months of preparation with the community nursing team and the family the baby can finally go home.

Learning all the cares involved with taking care of a child with a tracheostomy. Such as – suctioning the tube, cleaning around the stoma, changing the tracheostomy tube. Infant Basic life support.

Tracheostomy – how long for?

• Most of the children who get tracheostomy as a baby will get them out before they are 5.

• It depends from child to child how long they will need the tracheostomy.

• Minimum time is two years.

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Advancements in anaesthesia

◦ I have nothing to disclose

Dr Georgi Valchev Consultant anaesthetist Mater Misericordiae University Hospital‐ Dublin

Advancements in anaesthesia

William Thomas Green Morton (1819‐68) ‐ American dentist who first publicly demonstrated the use of inhaled ether as a surgical anaesthetic in 1846 .

William Thomas Green Morton (1819‐68)

On 30 September 1846, he administered diethyl ether to Eben Frost, a music teacher from Boston, for a dental extraction.

Advancements in anaesthesia

William Thomas Green Morton (1819‐68)

On 16 October 1846, John Collins Warren removed a tumour from the neck of Edward Gilbert Abbott a local printer at Massachusetts General Hospital. Diethyl ether was used as a general anaesthetic.

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Advancements in anaesthesia

• In 1847 Scottish obstetrician James Young Simpson (1811–1870) of Edinburgh was the first to use chloroform as a general anaesthetic on a human • John Show (1813‐1858)become the most experienced British physician working with the new anaesthetic gases of ether and chloroform thus becoming, the first British anaesthetist and in 1853 Queen Victoria's accoucheurs invited John Snow to anesthetize the Queen for the birth of her eighth child • In 1860 Albert Niemann isolated cocaine‐ the first local anaesthetic. • In 1880 , the Scottish surgeon WIliam Macewer (1848–1924) reported on his use of orotracheal intubation • In 1898 the first planned spinal anaesthesia for surgery in man was administered by August Bier (1861–1949)

• In 1913 Chevalier Jackson (1865–1958) was the first to report a high rate of success for the use of direct laryngoscopy • In 1928 Arthur Ernest Guedel (1883‐1956)introduced the cuffed endotracheal tube • In 1934 Sodium Tiopental , the first intravenous anaesthetic, was synthesized by Ernest H. Volwiler (1893–1992) and Donalee L. Tabern (1900–1974) • In 1943 Sir Robert Reynolds Macintosh (1897–1989)he introduced his new curved laryngoscope blade • In 1960 Paul Janssen’s (1926‐2003) team synthesised Fentanyl

Advancements in anaesthesia

• Propofol was discovered in 1 977 by John B. Glen , a British veterinarian and researcher at Imperial Chemical Industries and approved for use in the United States in 1989. • It is on the WHO’s List of Essential Medicines, the most effective and safe medicines needed in a health system. • The currently available preparation is 1% propofol, 10% soybean oil, and 1.2% purified egg phospholipid as an emulsifier, with 2.25% glycerol as a tonicity ‐adjusting agent, and sodium hydroxide to adjust the pH

Archie Brain (born 1942) is a British anaesthetist best known as the inventor of the laryngeal mask in 1987 The LMA™ has been used over 300 million times worldwide in elective anaesthesia and emergency airway management

Advancements in anaesthesia

• In 1975 Sevoflurane was discovered by Ross Terrell and independently by Bernard M Regan. • It was introduced into clinical practice initially in Japan in 1990 by Maruishi Pharmaceutical Co., Ltd. Osaka, Japan. • In 1994 Rocuronium was introduced in the clinical practice • In 2009 Suagammadex was widely available as reversal agent

1996 – Bulgaria, Stara Zagora, Trakia University

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Advancements in anaesthesia

1998 ,Bulgaria,Plovdiv,M BALPlovdiv

35 yearsold patient,bleeding ulcer,Hb-7,0, HR-130/m in,NIBP –80/40,O 2 Sat94% -RA

2019,Dublin,M M UH

65 yearsold patient,single lung transplant, HR-130/m in,NIBP –80/40,pre op ECM O insertion,O 2 Sat94% -High flow O 2,

Advancements in anaesthesia

Advancem entsin anaesthesia

• Patient safety • Patient experience • Patient pain management • The new profile of the anesthesiologist

TenediosC,O ’LearyS and CapocciM etal.European JournalofAnaesthesiology 2018;35:158-164

Advancements in anaesthesia

Patient safety

Patient safety New approaches to clinical airway management: • DAS airway algorithms • video laryngoscopy (including AFOI intubation) • extubation catheters • advanced supraglottic airway devices

• In 1980 pulse oximetry • In 1991 capnography – could have helped in prevention of 93 % of all anaesthesia related incidents • In 2008 WHO Surgical Safety Checklist and Implementation Manual

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Advancements in anaesthesia

Patient safety

Advancements in anaesthesia

Patient safety International standards for continuous real‐time monitoring of : • haemodynamic • oxygenation • ventilation • neurological status • urine output • core temperature • degree of neuromuscular blockade • dept of anaesthesia

Patient safety The implementation of the US machines in the routine anaesthetic practice: • US guided regional anaesthesia • US guided vascular accsess • POCUS • conventional and 3D‐ echocardiography for real‐time monitoring of valvular function, ventricular filling, cardiac contractility and other hemodynamic parameters

Advancements in anaesthesia

Patient safety The use of e‐ tablets and smartphones in the clinical practice: ‐ Butterfly iQ ‐ GE

Patient safety

Clinicalearlywarning algorithm sfor: • LAST • Malignant Hyperthermia • Anaphylaxis • Sepsis

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Advancements in anaesthesia

Patient safety Very well‐established special units‐ PACU,HDU and ICU Perioperative medicine

Smartphone and e tablets anaesthesia Tele‐anaesthesia Robot guided anaesthesia Nano anaesthesia Genetically target anaesthesia Artificial intelligence in anaesthetsia

Advancements in anaesthesia

New profile of the anaesthesiologist

Patient experience • Patient experience is about delivering safe, high‐quality, patient‐centric care • PONV, postoperative pain management, and communication with the anaesthetist are the most important features • A good patient experience is part of a successful anaesthetic • Regular audits and feedback from the patients and the staff

Anaesthesia service : • in OR • hospital outside of OR • clinic based • surgery centres

Advancements in anaesthesia

New profile of the anaesthesiologist

Non ‐anaesthesia service : • pain • HDU/ICU • palliative care • perioperative medicine • care coordination

• Education‐ PCS • Well being in anaesthesia • Risk and resilience

• research and teaching • administrative duties

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Advancements in anaesthesia

New profile of the anaesthesiologist

• Education‐ PCS • Well being in anaesthesia • Transplants , elderly, patient with congenital hearts and complex cases • Risk and resilience

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Overview

The Coroner & Coroners (Amendment) Act 2019 ODN Conference – 30 th November 2019 Dr Edward Mathews, RNID, LL.B, LL.M, Ph.D., BL Director of Professional and Regulatory Services

• Role of the Coroner • Investigation

– Post‐Mortem & Potential Inquest

• Mandatory Reporting • Who must report? • When will an Inquest be held? • The Inquest process • Giving evidence • Preparation • Key reforms under the Coroners (Amendment) Act 2019

Role of the Coroner • State official who must be either legally qualified or medically qualified, or both • And who makes legal determinations in relation to the cause of death and circumstances of death • The central role of the coroner is the investigation and certification of death in circumstances where there is some question or lack of clarity concerning that death • In essence ‐ where there are unexpected or unexplained deaths

Role of the Coroner • In many cases the coroner needs to do little more than satisfy themselves that no further inquiry is necessary • However, where necessary they have powers to facilitate a broader investigation or inquest

Role of the Coroner ‐ Investigation • The investigation will generally take the form of a post‐mortem • Whereas the inquest is a formal exercise where the coroner, with or without a jury, hears sworn evidence to establish the cause of death without apportioning blame

Role of the Coroner – Post‐Mortem • In terms of a post‐mortem, there is a general discretion invested in the coroner as to whether one is necessary • However, section 21 of the 2019 Act inserts section 33B which directs certain cases where a post‐mortem must take place

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Role of the Coroner – Post‐Mortem • Mandatory post‐mortems where: – (a) the death of the person may, in the opinion of the coroner, have occurred in a violent or unnatural manner, or in suspicious circumstances; – (b) the death of the person may, in the opinion of the coroner, have occurred unexpectedly and from unknown causes or in an unexplained manner; – (c) the deceased person was, at the time of his or her death or immediately before his or her death, in State custody or detention; – (d) the death of the person was a maternal death or a late maternal death; – (e) the death of the person may, in the opinion of the coroner, have occurred in circumstances which, under provisions in that behalf in any other enactment, require that an inquest should be held; – (f) the death of the person occurred as a result of an accident at work or was due to an industrial or occupational injury or disease or industrial poisoning.

Role of the Coroner – Post‐Mortem • Mandatory post‐mortems where: – (a) a member of the Garda Síochána not below the rank of inspector in any case other than a case to which paragraph (d) applies, – (b) a member of the Defence Forces not below the rank of commandant in a case of the death of a person who is subject to military law under the Defence Acts 1954 to 2015, – (c) a duly authorised officer of a statutory body who is empowered under another enactment to investigate accidents, incidents or diseases resulting in death in a case in which the body is investigating the accident, incident or disease resulting in the death concerned, or – (d) a designated officer of the Ombudsman Commission in a case in which there is a relevant Ombudsman Commission investigation, – requests him or her so to do, and states the reasons for such request in writing.

Role of the Coroner ‐ Inquest • The object of an inquest, associated as it is with the role of the coroner, is to establish answers to

Role of the Coroner ‐ Inquest • The process establishes the facts surrounding the death, places these on the public record and answers the relevant questions. • While the coroner may make recommendations to prevent the reoccurrence of such deaths or recommendations that are desirable in the interests of public health and safety … • Neither the coroner nor inquest process may establish or apportion any blame for the death which occurred – either criminal or civil

four basic questions: – Who is the deceased?

– How did the deceased die? – When did the deceased die? – Where did the death occur?

– To the extent that the coroner holding the inquest considers it necessary, the circumstances in which the death occurred

When must a death be reported to the Coroner? • There are wide range of cases in which a report must be made to a coroner, and these are determined in law and by local practice. • Essentially any sudden or unexplained death must be reported, and even in cases of suspected natural causes where the person has not been seen by a medical practitioner for a month prior to death

Section 9 – 2019 Act (s 16A) • (1) The following shall be a reportable death for the purposes of this Act (in this Act referred to as a ‘reportable death’): • (a) the death of a person which occurred, or may have occurred, either directly or indirectly— – (i) in a violent or unnatural manner or by unfair means, – (ii) by misadventure, – (iii) unexpectedly and from unknown causes or in an unexplainedmanner, – (iv) as a result of negligence,misconduct or malpractice on the part of others, or – (v) in such circumstancesas may, in the public interest, require investigation; • (b) the death of a person which occurred, or may have occurred, either directly or indirectly, from any cause other than natural illness or disease for which the person had been seen and treated by a registered medical practitioner within one month before his or her death; • (c) subject to paragraphs (a) and (b), the death of a person which occurred, or may have occurred, at a place or in circumstances which, under provisions in that behalf in any other enactment, require that an inquest should be held.

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When must a death be reported to the Coroner? • The Schedule to the Coroners (Amendment) Act 2019 specifies a list of circumstances where a report must be made – notwithstanding the foregoing provisions • Consideration of the Schedule shows that many deaths occurring in, or arriving in, the ED will be reportable

Who must report?

• Section 9 2019 Act (s16B) – A person specified … shall, as soon as practicable after becoming aware of a reportable death – Unless he or she has reasonable grounds for believing that the death has already been reported to the coroner by another person specified in whichever of those subsections is appropriate – Report, or cause to be reported, the death to the coroner for the district in which the body is lying – Failure to do so is an offence

Who must report?

• Section 9 2019 Act (s16B) – any medical practitioner, nurse or midwife who had responsibility for, or involvement in, the treatment or care of the deceased person in the period immediately before his or her death or who was present at his or her death; – any registered medical practitioner who examines the body of the deceased person after death; – any paramedic or advanced paramedic, who had responsibility for, or involvement in, the care of the deceased person in the period immediately before his or her death or who was present at his or her death

• Section 9 2019 Act (s16B) – If the reportable death concerned is that of a stillborn child or a death intrapartum – Any medical practitioner, nurse or midwife who had responsibility for, or involvement in, the treatment or care of the woman concerned in the period immediately before or after the delivery of the stillborn child, or who was present at the delivery – Is required to report, or cause to be reported, the death … to the coroner concerned

Who must report?

• Section 9 2019 Act (s16B) – The obligation imposed on a person … shall be deemed to be discharged if he or she reports the death as soon as practicable after becoming aware of it to a member of the Garda Síochána – It shall be the duty of a member of the Garda Síochána, on becoming aware of a reportable death … to report the death as soon as practicable to the coroner for the district in which the body is lying

• Section 9 2019 Act (s16B) – Any person who reports a death pursuant to this section shall give to the coroner (or, as the case may be, a member of the Garda Síochána) … – All such information available to him or her as may assist the coroner in the performance of his or her functions under this Act

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Coroners Response • The coroner need not investigate or hold an inquest in every case, and if they are satisfied following informal inquiries that nothing untoward has occurred, they may direct the issuing of death notification certificate • However, they may conduct further investigations in the form of a post‐mortem examination, and if satisfied that the cause of death was natural causes may then issue a Coroners Certificate • However, in other circumstances the coroner may decide to hold an inquest

Inquest • In most instances the coroner has a discretion as to whether to convene an inquest • However, one must be convened where death is suspected to have occurred in violent or unnatural circumstances or unexpectedly and of unknown cause

Inquest • The 2019 Act, while retaining the foregoing provisions now also requires an Inquest where: – The deceased person was, at the time of his or her death or immediately before his or her death, in State custody or detention; – The death of the person is a maternal death or a late maternal death

Inquest • An inquest may sit with or without a jury, but a jury must be involved, where: – Death may be due to homicide (or a suspicious death); – Death occurred in prison; – Death was caused by accident, poisoning or disease requiring notification to be given to a Government Department or inspector; – Death occurred in circumstances which may be prejudicial to the health or safety of the public; – The Coroner considers it desirable to hold an inquest with a jury.

Inquest Process • The inquest seeks to establish the facts surrounding the death, and to answer the four questions • In theory, the inquest is an inquisitorial process, in that it is not one side versus the other, and instead is an inquiry into the circumstances surrounding the death without the attribution of blame • The inquest involves the coroner hearing evidence from witnesses, and these may include those involved in the care of a person prior to and at the time of their death • The coroner is the person who determines from whom evidence may be taken

Inquest Process • Evidence may be given in writing or orally, or both • Written evidence normally takes the form of a deposition, and advice should be sought prior to making such a submission to an inquest • If directed to attend an inquest to give oral evidence then a refusal to attend (without reasonable excuse), may lead to High Court Proceedings directing attendance • Again, advice should be sought prior to attending to give oral evidence

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Inquest Process • Under the 2019 Act the Coroner has enhanced powers, such as: – Directing the answering of questions; – Direct production of documents, records, things etc; – Failure to answer questions/produce articles etc may lead to High Court proceedings to directing compliance

Inquest Process • Having heard the evidence the coroner, or jury as the case may be, returns a verdict which establishes the answers to the foregoing questions, and essentially the cause of death • The verdict may be relatively brief or take a more extensive narrative form

Inquest Process • Common verdicts associated with cases where nurses and midwives may be called to give

Inquest Process • While recommendations may also be made, again no blame may be attributed – either civil or criminal

evidence include: – Accidental death;

– Death by misadventure; – Medical misadventure; – Suicide/Self inflicted death; – Want of attention at birth; – Stillbirth; – Death by natural causes; – Open verdict.

Giving Evidence • The primary purpose of the inquest is to establish the circumstances of the death, and as such in theory it should be an uncontentious exercise for a witness whereby, they give an account of relevant matters, and indeed this is what occurs in most cases • However, some cases may be more contentious where different witnesses have differing accounts of what occurred • Additionally, the facility for certain persons to ask questions can give rise to a degree of contention

Giving Evidence • Questions may be asked of witnesses by the coroner. • Also, any person who has a proper interest in the inquest (a properly interested person) may personally examine a witness or be legally represented by a solicitor or barrister

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Giving Evidence • Properly interested persons include: – the family and next‐of‐kin of the deceased; – personal representatives of the deceased;

Giving Evidence • Properly interested persons may not call evidence • But they may question witnesses on matters relevant to the death • This has led some nurses and midwives to experience sustained and difficult questioning • Especially where there is a conflict of fact, or where a family are trying to establish that the death was associated with some want of care

– representatives of a board or authority in whose care the deceased was at the time of death e.g. hospital, prison or other institution; – those who may have caused death in some way e.g. driver of a motor vehicle; – representatives of insurance companies; – (Where death resulted from an incident at work) ‐ • representatives of trade unions; • employer of the deceased;

• inspector of the Health and Safety Authority – others at the discretion of the coroner.

Preparation for the Inquest • Preparation is crucial and is essentially divided into two categories – Personal preparation – Appropriate engagement with your representative

Personal Preparation

• Read all the notes carefully; • Ensure you have a chronological account of what occurred, when it occurred, why it occurred, who was there, and what happened afterwards; • Remember look at the person asking questions, then direct your answer to the coroner; • Do not engage in any argument with the person asking questions, ask for a break if necessary and try to remain calm; • Tell the truth and remain focused on what occurred

Preparation with a Representative • Your employer is obliged to provide you with a competent and impartial legal representative at the inquest; • You must have time to consult with your representative before the inquest, and you must seek their advice before making any written submission; • Ask your representative if there is any conflict between you and anyone else they are representing (your colleagues or the employer), if there is, seek another representative from your employer; • Ask your representative for advice on the type of questions you will face, and how to best deal with the process; • Ask your representative are they sure they can legally represent your best interests at the inquest

INMO Assistance • If you encounter any difficulties with accessing a representative from your employer, or with the conduct of the representative, please contact your INMO Official immediately, who will in turn seek an alternative representative from your employer

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Key Reforms in the 2019 Act • The Act makes provision for mandatory reporting to a coroner, and investigation and inquest by a coroner, of a maternal death or late maternal death, and for legal aid for a family member at an inquest into such a death • The definitions used regarding maternal death or late maternal death accord with those used by the World Health Organisation (WHO‐ICD). • The Act further provides for mandatory reporting to a coroner of a stillbirth, death intrapartum, or infant death

Key Reforms in the 2019 Act • The Act also re‐states and clarifies the deaths in State custody or detention which are subject to mandatory reporting, post‐mortem examination and inquest, and where provision is made for legal aid to a family member of the deceased at inquest.

Key Reforms in the 2019 Act • The Act widens the scope of an inquest – – from investigating the proximate medical cause of death; – to establishing in what circumstances the deceased met his or her death, to the extent that the coroner considers necessary in that case.

Key Reforms in the 2019 Act • The Act makes provision for, and clarifies: – What deaths must be reported, and – Who must report

Key Reforms in the 2019 Act • The Act revises the circumstances in which a post‐mortem is mandatory • The Act makes provision to allow the Coroner direct the release of medical records for the purposes of assisting the post‐mortem examination • The Coroner is given enhanced powers in relation to procuring evidence

Thank you

Questions?

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Cholecystectomy in sickle cell disease

Case Study Maureen Ogan PgDip Peri-op Nursing

Aims & Objectives • Anatomy of the gall bladder

Introduction • Sickle cell disease (SCD) is a genetic haemoglobinopathy • Most common in Afro-Caribbean and African people • Diagnosed in childhood with life long complications • SCD patients have progressive organ damage • Sickle cell disease is more symptomatic than sickle cell trait • 50% of adult patients with SCD get cholecystitis • Surgery for SCD patients triggers the disease related complications • Prognosis for these patients has improved in recent times hence awareness is important.

• To define Cholecystitis and Predisposing factors • Symptoms & investigations of cholecystitis • To explain sickle cell Disease : Anatomy, Epidemiology • Indications and types of sickle cell disease

• To present a surgical cholecystectomy case study for cholecystitis with sickle cell disease • To outline the peri-operative nursing care of the patient and post-operative complications of this procedure. • To provide awareness of sickle cell disease and its implication for surgical patients undergoing cholecystectomy.

Anatomy of Gallbladder

Cholecystitis Define It is the inflammation of the gall bladder which can happen suddenly (acute) or over a long period (chronic).

Predisposing Factors • Race and demography • Obesity • Age • Haemolysis syndromes • Biliary infections • Gall bladder cancer

• Inflammatory bowel disorder • Ileal resection or bypass • Cystic fibrosis • Chronic pancreatitis • Cirrhosis (Rothrock 2011)

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Pigment stone / Bilirubin stone

Types of gall stones • Cholesterol stones • Pigment stones / Biliribin stones • Mixed stones • Stones with calcium content 15% of gall stones in the general public is pigmented whereas majority of gall stones in SCD patients are pigmented. (Vasavda et, al., 2007)

• By-product of haemolysis • Causes extrahepatic obstruction • Causes cholecystitis • Affects 50% of adult patients with HbS • Cholecystectomy indicated if patient is symptomatic.

(Schnall & Benz, 2002)

Cholecystitis

Surgical Management

Symptoms • Abdominal pain localising in the right upper quadrant sometimes radiating towards right shoulder. • Persistent pain • Fever • Nausea and vomiting • Sweating • Loss of appetite • Jaundice • Bulge in the abdomen

Investigations

Laparoscopy is an approach to abdominal surgery for minimal access into the abdomen to achieve the same surgical result as open laparotomy. It is also referred to as minimally invasive surgery where surgery is performed with instruments manipulated from outside the patient’s body.

• Blood tests; Hb, U&E, Liver function tests • Abdominal ultrasound screening • ERCP • Sometimes MRCP

(Rothrock, 2011)

Laparoscopic cholecystectomy • Preferred technique as it posses less risk to the patient • Gold standard for treatment • Elective procedure for symptomatic cholelithaisis (gallstones) • Minimally invasive • Less scaring • Reduced rate of infection • Reduced length of hospital stay • Day case procedure

Laparoscopic cholecystectomy

Benefits for patient • Minimal blood loss

Benefits for surgeon • Enhanced imaging resolution • Image/video recording option • All team members see the same image • Abundant light and magnification

• Reduced risk of infection • Rapid return of GI function • Less small bowel obstruction • Reduced risk of incisional hernia with small incision • Less post op pain and reduced analgesia use

(Rothrock, 2011).

(Rothrock, 2011)

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Epidemiology In 2010 the World Health Organisation (WHO) labelled SCD as a global health problem, with a world wide neonatal incidence of 294,000-330,000. It was previously isolated to sub-Saharan Africa, India and parts of the Mediterranean and Middle-East.

Sickle Cell Disease (SCD) Sickle cell disease (SCD) is a genetic condition caused by a gene mutation that affects protein structure producing haemoglobins. (Burner & Suddarths 2012). SCD is the commonest haemoglobinopathy in man. It is an autosomal recessive condition that leads to abnormal structured and functioning red cells that have shortened life span, or poor capacity to carry oxygen and a tendency to occlude micro vascular spaces. Significant morbidity and mortality result from organ sequestration, occlusion and sepsis. (Gibbons et. al 2015)

Globalisation and immigration has caused a shift in the geographic location of these individuals with SCD.

Current surge in the population with SCD is shown in an epidemiology study in 2005 which identified 160 children with SCD in Ireland. In some European countries SCD has become the most common genetic condition overtaking cystic fibrosis. (Roberts & DeMontalemdert, 2007).

Who needs to be tested The 2003 National Institute for Health and Care Excellence (NICE) guidelines advice that it is relevant to test all North African, West African, South/sub-Saharan Africa and Afro Caribbean patients including other ethnic groups considered to be at risk.

Aetiology • It is genetic • Individual must inherit the recessive gene form both parents • The term Sickle cell anaemia is used to refer to HbSS disease • The term SCD is used to represent all the genotypes HbSS,HbSC,HbSβ-thalassemia PROGNOSIS: Diagnosed in childhood, some children die in the first years of life, however symptoms and complications are better managed to support an average life expectancy of 42-48yrs. In some patients symptoms diminish by 30yrs of age which allow them to reach the 6 th decade of life. (Rees et, al. 2010)

It is also prevalent in people among people from South and Central America, some Eastern Mediterranean, Middle-East and Asia

There is an increase in race mixing which can be deceptive with who gets tested .

Anatomy of sickle blood

Sickle Cell Anaemia vs Sickle Cell Trait

• This gene causes red blood cell molecule to be defective. • The sickle haemoglobin S (HbS) acquires a crystal-like formation when exposed to low oxygen tension, hence the erythrocyte containing HbS changes shape from round pliable biconcave disc shape it becomes • Rigid and sickle in shape. ( Schnall & Benz, 2002)

• As for sickle cell trait, they don’t have the condition but they have one of the genes that cause the condition i.e. If HbS is inherited from one parent and a normal Hb from the other parent. • An individual with sickle cell anaemia and sickle cell trait can pass the gene on when they have children.

• In sickle cell anaemia it is inherited, life long disease, symptoms are profound and frequent • Individual inherits two copies of the gene, one from each parent HbSS genotype.

(Schnall & Benz, 2002)

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Pathophysiology of SCD RBCs -hard, sticky, sickle shaped

Vaso-occlusion

Haemolysis

S/S ofhypoxia due to anaemia, reduced circulationand pulmonary complications of SCD

Anaemia

Cholecystitisusuallydue toCholelithiasis (haemolysis causes increasedbilirubin which causesgallstones

Impaired circulation to major organs

Lung-acutechest syndrome Pulmonary infarcts

Cerebral infarcts Splenicatrophy

Abdominal pain

Jaundice (due to increased bilirubin)and abnormalLFTs

Nauseaand vomiting

Feverdue to inflammatory process

Cholecystitis in relation SCD

Physiological process • Haemolysis

• Studies show that up to 50% of children with SCD develop gall stones, often referred to as pigment stones and should be investigated with a screening ultrasound. • Studies show that haemolysis comes with several complications such as cholecystitis, cuteanous leg ulceration, priaprism and pulmonary hypertension. (Rees, et. al. 2010) • Cholecystectomy is the most frequent surgical procedure performed in SCD patients with the preference of laparoscopic surgery as it reduces the patients hospital stay without exposing the patient to SCD complications. This technique is recommended over open cholecystectomy.

• Micro-vascular circulation occlusion

• Ischemia or infarction of tissues supplied by occluded vessels. This is the dominant cause of morbidity and mortality.

• Vaso-occlusive crisis is a painful infarctive crisis which presents with fever, tachycardia and leucocytosis. These are commonly precipitated by infection, fever, pregnancy, cold, dehydration, stress and surgery.

(Schnall & Benz, 2002)

• As the presentation is acute and with further investigations my patient and parents were informed of the need for surgery.

Case study Master George Foreman is a 17years old teenager of Afro-Caribbean origin, presenting to A&E with recurrent pain in the right upper abdomen, episodes of jaundice, low fever of 37.6ºC, bloating, nausea and vomiting. Surgical history: Circumcision Medical history : SCD diagnosed at 9 months, none functioning spleen, asthma He attends haematology clinic as part of his ongoing care. Frequent admissions to hospital following infections and vaso-occlusive crisis associated with SCD. Weight 58kg, No known drug allergies Medication: ibuprofen, oxycontin, oxynorm, lansoprazole Diagnosis: Cholecystitis

The SCD patient in surgery

Primary aim for these patient group is to manage triggers of sickle cell related crisis

• Hypoxia • Acidosis

• Hypothermia • Hypovolemia

Anasthestetic agents and surgery can induce the above in a surgical patient and hence should be managed but extra considerations should be in place for patients with sickle cell disease. (Firth & Head, 2004)

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Preoperative assessment • The pre operative management of sickle cell disease requires specialised knowledge and vigilance by the anaesthetists along with cooperation between many specialities. • Checking for signs of vaso-occlusion, fever, infection, dehydration and sequelae of the disease particularly pulmonary. • Intraoperatively anaesthesia may be achieved by either general or regional anaesthesia to avoid hypoxia, hypovolemia, hyper viscosity, acidosis and hypotension being the cornerstone of care. (Fanning et. al, 2006)

Preoperative assessment • Identify risks of peri-operative SCD complications and organ dysfunction with the intention of preventing or anticipating these problems.

• Identify patients risks (i.e.) type of surgery, disease activity, patient details and organ dysfunction following disease progression.

• Establish the most recent acute exacerbation of SCD (i.e.) last vaso- occlusive crisis, pain or any symptoms associated.

• Assess for the presence of silent/cryptic pulmonary, renal or neurologic vasculopathy that maybe unmasked in the surgical patient.

• Renal pathology is an important pre-operative objective, as SCD patients have significantly lower blood pressure than the general population. (Firth & Head, 2004)

Patient care

Pre-operative preparations

• Blood tests (FBC, U&E with CRP, LFTs), chest x-ray, pulmonary function tests, ABGs, ECHO and neurological imaging. • Prophylactic transfusion: X-match Rhesus antigen • Patient was kept NPO • IV fluids commenced as prescribed to maintain hydration in my patient during the period of fasting. • Consent for surgery by parents and patient

• General anaesthesia • Surgical and anaesthetic team briefing • Perioperative checklist is completed by the anaesthetic nurse • Weight, allergy status, past medical and surgical history, any reaction to the previous anaesthesia . • Current medication, any pain relief • Infection status, • Baseline vital signs

Intraoperative Nursing Care • Surgical safety pause observed • Patient in supine position on the table top with arms by the side pressure areas protected • Safe positioning aids used to appropriately secure the patient. • Maintain patient dignity • Diathermy pad applied • Aseptic solution used to cleanse the skin • Aseptic draping to provide good surgical site exposure • Video imaging equipment, and co2 dispenser, suction machine, diathermy machine.

Anaesthetic Nursing Care

• Time out :With the anaesthetic nurse, anaesthetist and patient confirming patients full name as known to the hospital, date of birth, MRN, allergy status and consent ensuring that patient had a good understanding of the surgery. • Sufficient pre-oxygenation • ET size 7 cuffed tube • Temperature probe inserted • Antibiotics: Augmentin and Flagyl as per surgeon’s recommendation. • Avoid the use of Nitrous oxide- risk of pulmonary complication

• Baseline temperature was 36.5⁰C. Temperature monitoring is very important for my patient as low core body temperature is a precipitant of SCD related pain (vaso- occlusive crisis). In addition the use of anaesthetic agents may further reduce his body temperature. Hence an external warming device was applied. In a recent audit on patient temperature in patients arriving to this department showed that patients drop their temperature rapidly at every stage from the holding bay till they arrive in the recovery room. (AAGBI, 2009)

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Procedural Considerations

Intraoperative Nursing Care

Procedure commenced. Four incisions each likened to small stab were made to the abdomen. • Umbilical incision, blunt laparoscopic port inserted for the camera • Right upper quadrant incision for a 5mm port and a grasping forceps

• The theatre nurse is the patient's advocate • Monitor fluid loss • Vital signs monitor for anaesthesia induced hypotension • Thermoregulation: warm irrigation fluid • Specimen care: correct label and handling • Give local anaesthetic if agreed by the anaesthetist

• Right lower quadrant incision for second 5mm port • Left upper quadrant incision for a third 5mm port

Procedural Considerations Laparoscopic instruments • Endoscopic suction and irrigation device • Light handle • Needle counter box • Anti fog for camera cleaning • Raytec swabs (10X10) 10 pieces, (30X30) 10 pieces • Blade 15 • Sutures as preferred • Wound dressing

Post operative care/recovery

Surgical Set Up/Drapping

In recovery room • Oxygen supplement • IV hydration till oral diet • Monitor vitals • Pain management • Monitor level of consciousness • Incentive spirometry • Repeat routine bloods-FBC • Blood gas- monitor for acidosis

On the ward • Early ambulation as tolerated to avoid venous stasis • Monitor for pulmonary complications acute chest • Continue pain management in this patient • Psychological and emotional care • Family care Outcome • Surgery was successful • Pain aptly managed • Sickle cell related complications well controlled • Discharged on day 2 post surgery.

• Maintain temperature • Assess surgical sites • Monitor abdomen for bleeding • Monitor for complications from CO2 use

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SUMMARY

Any Questions?

• Multi-disciplinary team care is imperative for appropriate management. • Anaesthetists need to be aware of the possible serious complications of sickle cell disease in the perioperative period. • Management of these patients requires careful preparation, and close attention to those factors that can precipitate a sickle crisis. • The basic principles of oxygenation, hydration, analgesia, avoidance of hypothermia and acidosis, and blood transfusion where indicated, are essential in these patients .

(AAGBI, 2009)

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Objectives for Today

Unleashing the Power of your Emotional Intelligence Dr Eva Doherty, Director of Human Factors in Patient Safety

• What is Emotional Intelligence

• How can we become even more emotionally intelligent

RCSIDEVELOPINGHEALTHCARELEADERSWHOMAKEADIFFERENCEWORLDWIDE

Does it matter how you feel?

You might have heard of EI / EQ………

Afraid

Surprised

High

Angry

Happy

Pleased

Annoyed

Content

Sad

Calm

Bored

Tired

Low

Unpleasant

Pleasant

Emotion

Is EI relevant for nurses? Sampling the evidence

The science of EI …

Began in 1990 by Salovey & Mayer

• CodierE.,CodierDD (2017) CouldEmotionalIntelligenceMakePatientsSafer?Specific skillsmighthelpnurses to improve communication,conflict resolution,and individualand teamperformance. AmerJNurs 117(7):58‐62

Emotional intelligence is "the ability to monitor one's own and others' feelings and emotions, to discriminate among them, and to use this information to guide one's thinking and action".

• MichelangeloL. (2016) Theoverall impactofemotional intelligenceonnursing studentsandnursing. Asia‐Pacific JOncolNurs 2(2):118‐ 124.

• HolberyN. (2015) Emotional intelligence‐essential for traumanursing, IntEmNurs 23:13‐16.

• TaylorB.,RobertsS.,SmythT.,TullochM. (2015) NurseManagers’ strategies for feeling lessdrainedby theirwork:anaction research and reflectionproject fordevelopingemotional intelligence, JNursMan,23:879‐887.

• ShataL.,GargiuloL.(2014) AStudyof the InfluenceofNursingEducationonDevelopmentofEmotional Intelligence JProfNurs, 30:511‐ 520

• PorJ.,BarribalL., Fitzpatrick JRoberts J (2011) Emotional intelligence: Its relationship to stress, coping,well‐beingandprofessional performance innursing students, NursEdToday ,31:855‐860.

• SmithKB.,Profetto‐McGrath J.,&CummingsGC (2009) Emotional intelligenceandnursing:An integrative literature review IntJNurs Stud :1624‐1636

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A blueprint for emotions…

Evidence re EI……….. relates to:

How are these emotions directing and impacting thinking?

What emotions are you, and others, experiencing?

• Well-being • Teamwork • Critical thinking

IDENTIFY

• Ethical decision-making • Problem-focussed coping • Leadership • Quality of patient care • Safety (eg infections and falls) • Patient outcomes

MANAGE

USE

UNDERSTAND

How do you manage your emotions and other’s emotions?

What caused these emotions? How might these emotions change?

Emotional Intelligence relates to:

Emotional Intelligence is:

• Greater empathy for others • More positive behaviors • Less ‘negative’ behaviours • Better quality social relationships • Enhanced communication • Social support • Teamwork

• A hard skill • A form of intelligence

Where • You think about emotions, and • Emotions help you think

………However, its not all about being nice!

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