Surgical Procedure
This first incision was made at 10:25am into the left thoracic wall, cranial to the abdominal wall, around the mass (see image 6). The mass was then resected allowing 2cm margins around the original circumference which resulted in a 14cm x 12cm mass. 6 ribs were also resected during the process. It was noted that the thorax was clear and the lungs looked normal (see image 7). The chest tube was then placed. The diaphragm was advanced and attached to rib 7 and the proximal resected rib ends. The defect was then moved into the abdominal cavity where it was closed with an omental flap in a continuous pattern using PDS 3/0[1] suture material (see image 8 and 9). Polypropylene mesh was then sutured into the defect in an interrupted mattress pattern using PDS 2/0[2] suture material (see image 10 and 11). The closed suction drain was then placed and the cutaneous trunci was sutured with monocryl 3/0[3]. Lastly, the skin was sutured using ethilon 3/0[4] in an interrupted pattern (Walker, 2010). Surgery was completed at 12:25pm.
Anaesthetic
At 8:15am, Tessa was premedicated with Atropine[5] 0.3mL and Morphine[6] 0.83mLs (see appendix). She was then taken for a 15 minute walk outside to allow her to alleviate herself and vomit if need be. She was then induced at 9:15am using firstly Diazepam[7] 0.4mLs and then Propofol[8] 3.3mLs (see appendix) into the intravenous catheter which had been previously placed into the right cephalic vein. She was then intubated at 9.17am using a size 5 endotracheal tube and it was secured using a maxillary tie. She was then attached to the anaesthetic machine which had a 0.5L (see appendix) reservoir bag attached. Her anaesthetic was maintained using Isoflurane gas[9] at varying percentages depending on her responses and oxygen at 2l/minute. Her anaesthetic was being constantly monitored and findings recorded every 5 minutes (see appendix).The factors that were being monitored throughout the procedure were heart rate and strength, respiration rate and pattern, mucous membrane colour, capillary refill time, palpebral reflex, oxygen saturation, blood pressure and carbon dioxide output. During the surgery, the patient was placed on an ECG to monitor the patterns of her heart. She remained stable during induction and while being prepped for surgery. Her heart rate was only 85 beats per minute throughout the majority of the surgery and blood pressure was stable at 110mmHg throughout. Due to the incision into the thoracic cavity, it was important to maintain the patient’s anaesthesia using intermittent positive pressure ventilation. This started at 10:35am and the patient was being ventilated at 15-18 breaths per minute until the thoracic cavity was sutured at 11:15am. Her capillary refill time remained at less than 2 seconds and her mucous membrane colour was pink during the entire surgery. The oxygen saturation readings also stayed within normal ranges for intermittent positive pressure ventilation. Once the thoracic cavity was closed, the patient was able to maintain carbon dioxide and oxygen saturation levels within the normal ranges. Nasal oxygen was placed and started once the patient was extubated at 12.42pm. She remained on the nasal oxygen overnight at a rate of 1 l/minute.
Fluid Therapy
In order to administer fluids during the patient’s stay, a 20 gauge intravenous catheter was placed into the right cephalic vein. The fluids that were used were Lactated Ringers Solution[10] which was connected to a 60 drop/mL giving set. Her maintenance fluid rate was calculated at 20.7mL/hour with a rate of 60mL/kg/day (see appendix). Her surgical rate was calculated to 83mL/hour with a rate of 10mL/kg/hour (see appendix). The patient remained on fluid therapy during her entire stay and also during the entire surgical procedure to ensure that hydration was maintained and also to aid the kidney function while the patient was under general anaesthesia (Brooks, 2010).
Pain Management
In order to alleviate the patient’s pain postoperatively, the patient was connected to a constant rate infusion pump through her intravenous catheter. Fentanyl[11] was administered alongside the Lactated Ringers Solution
. This was started at 10:00am, before surgery to allow it to take affect before the pain occurred. The rate was 0.4mL/hour for the first hour, 0.5mLs/hour for the next two hours, 0.8mLs/hour once she woke up as she was very vocal. This was then decreased to 0.7mL/hour once the patient calmed down. At 8:00am on Tuesday 14 September 2010, the patient was decreased to 0.6mL/ hour for the next two hours and then decreased again at 10:00am to 0.5mL/hour until the last dose was administered at 4:00pm the same day. Also after the surgical procedure, once the patient was fully awake, she was administered 0.66mLs of Carprofen[12] through subcutaneous injection at 1:00pm. The patient was then maintained on Carprofen[13] 20mg tablets which were to be administered as one tablet twice daily starting the following evening (Tuesday 14 September 2010) at 5:00pm (see appendix). Buprenorphine[14] was also started the following day. At 4:00pm, 0.45mLs was administered subcutaneously and was to be continued every 8 hours until the last dose was given on Wednesday 15 September 2010 at 12:00am. Fentanyl
was chosen for the patient as it increases the pain threshold of the patient and produces muscle relaxation (IVS, 2010). Carprofen
was chosen as it is a non-steroidal anti-inflammatory drug which helps to reduce any possibility of inflammation (Mathews, 2000).
[1] PDS 3/0 - Ethicon Ltd a Johnson and Johnson Company, Australia
[2] PDS 2/0 - Ethicon Ltd a Johnson and Johnson Company, Australia
[3] Monocryl 3/0 - Ethicon Ltd a Johnson and Johnson Company, Australia
[4] Ethilon 3/0 - Ethicon Ltd a Johnson and Johnson Company, Australia
[5] Atropine – Pheonix Pharm Distributors Ltd
[6] Morphine - Hameln Pharmaceutical, Germany
[7] Diazepam – Hameln Pharmaceuticals Ltd, United Kingdom
[8] Propofol – Norbrook New Zealand Ltd, New Zealand
[9]Isoflurane – Health support, New Zealand
[10] Lactated Ringers Solution – Baxter, New Zealand
[11] Fentanyl Injection - Astrazenica
[12] Rimadyl injectable – Pfizer Animal Health, New Zealand
[13] RImadyl tablets – Pfizer Animal Health, New Zealand
 |
| Image 6 |
 |
| Image 7 |
 |
| Image 8 |
 |
| Image 9 |
 |
| Image 10 |
 |
| Image 11 |