Challenges during anaesthetic management of a 38-year-old deaf and mute patient under general anaesthesia

Abstract

Congenitally deaf and mute adult patients have speech and language disabilities. Establishing meaningful communication with these patients is a challenge in acute hospital-care settings, particularly when anaesthetic care is to be provided. Several methods can be adopted to facilitate interaction, such as sensitisation of health-care providers and training them in ways to communicate effectively. A thorough preoperative assessment and customised perioperative management satisfying the patients needs will ensure a successful outcome. Implementing pain protocols and using tools such as Visual Analog Scale (VAS) will mitigate stress and surgical related complications.

Introduction

Patients who are both deaf and mute require proper preoperative preparation for a smooth postoperative recovery and are an anaesthetic challenge.^{1, 2} Assessing patients' communication skills, educational background and level of cooperation can help in planning the required preoperative preparation. Methods adopted to reduce stress in such patients and providing adequate postoperative analgesia will enable the patient to respond to postoperative care and be discharged early. Adopting a disability-specific approach to care for these deaf and mute patients will enable the patient to cope with the unfamiliar and sometimes-intimidating perioperative period. Greater involvement of the family members who understand the patient's requirements and can communicate better with him/her will help healthcare workers in providing better care for the special needs of the patient in the perioperative period.

Case report

A 38-year-old, congenitally deaf and mute female patient diagnosed with cholelithiasis was planned to undergo laparoscopic cholecystectomy. The patient was accompanied by her brother and father for the preoperative anaesthesia checkup who gave a reliable medical history. The father informed that his wife had consumed antibiotics in the first trimester (no record was available with the family). The patient was born premature at 7 months of gestational age and was diagnosed with congenital deafness at the age of four months, when the parents noticed that she was not responding to their voices and even loud sounds. She did not attend any formal school and received education through online courses. The patient had a good intellect and was responding well to all queries. She was also a known case of bronchial asthma, for which she took medication in the form of metered-dose inhaler of levosalbutamol, as and when required. She had no respiratory complaints during her visit to the preanaesthetic clinic.

General examination and her vital parameters were within normal limits. Her Metabolic Equivalents (METs) were above 5. Airway examination revealed an interincisor gap of 4.2 cm, and the Mallampati score was class 2 with normal dentition. Her systemic examination revealed no abnormality as well. Her blood investigations were within normal limits. The electrocardiogram showed a normal sinus rhythm with a Corrected QT interval (QTc) of 390ms. Chest radiograph was also normal. Ultrasound of the abdomen revealed cholelithiasis with grade I fatty liver. With the help of the patient's brother, the procedure of general anaesthesia for the proposed laparoscopic cholecystectomy was explained. Written informed consent was taken from the patient, and the patient was accepted in American Society of Anaesthesiologists (ASA) class II for laparoscopic cholecystectomy under general anaesthesia.

For familiarisation, the patient was called for a second visit to the Pre-anaesthetic check (PAC) clinic before her admission for the procedure. A video of the operation theatre was shown to the patient, and the procedure that would be followed on the day of surgery was explained. During the preoperative visit, focus was on educating and interacting with the patient and her relatives. Greetings in sign language were practised by the staff (using American Sign Language) to put her at ease. The anticipated postoperative course was explained, and she was taught to express pain by showing the visual analogue scale (VAS). The importance of recovery from anaesthesia was stressed, and it was emphasised that she should respond by opening her eyes when tapped twice on the forehead during this period.

On the day of surgery, the patient's brother was allowed inside the operating room so that she could feel comfortable. An 18-gauge intravenous cannula was secured, and monitoring was established according to the ASA standards, which included electrocardiography, pulse oximetry, non-invasive blood pressure, end-tidal carbon dioxide monitoring and temperature monitoring. The patient was induced with 2 mg/kg propofol and 1 mcg/kg fentanyl; the patient was intubated with a 7.5-mm cuffed endotracheal tube after administration of 0.6 mg/kg rocuronium bromide and was put on mechanical ventilation with a mixture of N₂O and oxygen at 2:1 ratio. Anaesthesia was maintained with isoflurane and required a single intermittent bolus of rocuronium bromide. The duration of surgery was 1 h and 30 min.

At the end of the surgery, an ultrasound-guided transversus abdominal plane block was given bilaterally with a total of 30 ml bupivacaine (0.25%). Reversal of neuromuscular blockade was achieved with neostigmine and glycopyrrolate, and the patient was extubated after she made eye contact on tapping her forehead. The family was permitted to visit her in the postoperative recovery unit before shifting her to the ward. The postoperative course was uneventful, with the VAS score never recorded more than 2 before discharge from the hospital. She was given intravenous paracetamol injection (1 g) only on demand.

Discussion

Children born with hearing loss cannot develop speech and language abilities. It limits their pursuit of higher education and future professional opportunities. Establishing meaningful communication is a challenge for them, and the magnitude of this challenge is far-reaching. The statistics are overwhelming. As per 2018 World Health Organization estimates, 466 million people suffer from disabling hearing loss worldwide, which forms 6.1% of the population, and the number could rise to 900 million by 2050. The prevalence in South Asia is 7.37%, affecting 131 million people.³ The incidence and prevalence in India are also very high.⁴

They are at risk of receiving limited information regarding their right to choose the anaesthetic techniques and understanding the details of the surgical procedures they are about to undergo and the inherent risks associated with both the surgery and anaesthesia. Establishing effective communication between the healthcare providers and these patients is the most challenging and a significant task.⁵ Our patient received formal education up to 10th standard. She was well versed with only basic sign language and relied more on lip reading for communication purposes when communication was done in English. Because she could read and write, communication was also possible by writing. She could easily comprehend facial expressions indicating feeling or opinion.

Sensitisation of all the healthcare providers, including surgeons, anaesthesiologists, nursing staff, operating room technicians and ward helpers, regarding the patients' condition and its inherent drawbacks will ensure a desired outcome. Various methods may be adopted to communicate with a deaf person customised to the patient's abilities, including written communication, graphic and non-tactile symbols, tactile symbols, gestures, facial expressions or manual and tactile sign language.⁶ Bispectral index monitors can be used effectively to assess recovery of patients with communication challenges. Frequently, people who are unable to properly communicate with a deaf person will chose to ignore them altogether. Therefore, basic training in communication methods will help in breaking barriers.

Soliciting help of the accompanying caregiver or family member or use of written communication will help in effective interaction with deaf and mute patients. Looking for more subtle cues such as changes in body language, breathing pattern or facial expressions will also help. Understanding their way of communication and using sign language if they do, such as the American Sign Language, will avoid miscommunication. It is also important to wait patiently before prompting a response from them.

Patients with poor educational background and low socioeconomic status will have limited access to healthcare and therapeutic options for hearing loss such as the cochlear implants. It has been shown that the level of education has the greatest impact on communication. Limited communicative abilities may affect the cognitive function of the person. They are also likely to have poorly developed social behaviours and deficiencies in expressing themselves. More than 50% cases of congenital hearing loss are due to genetic factors, and 30% of these are associated with various syndromes such as Alport, Jervell and Lange-Nielsen, Pendred, Stickler, Usher and Waardenburg syndrome and so on.⁷ Syndrome illnesses have specific anaesthetic significance such as long QT syndrome and difficult airway.⁸

Healthcare providers often have limited exposure to differently abled patients and may be unable to provide exclusive time owing to work overload. There may be inadequate resources due to absence of protocols and guidelines specific to these patients and non-availability of a communication specialist to facilitate the interaction.

Preoperative awareness of the patient regarding how the events will unfold will help in reducing anxiety, sleep disturbances and irritability and ensure cooperation. Permitting relatives to enter the operative area before induction of anaesthesia and immediately after recovery will mitigate stress.

Formulating a definitive and customised postoperative analgesic regime, such as the use of the VAS, will decrease stress and its associated undesirable conditions such as delayed gastric emptying, nausea, vomiting and paralytic ileus, which may lead to delayed mobilisation and discharge from the hospital. Various other tools can be used to measure pain in these patients, such as the Iowa Pain Thermometer or numeric rating scale, to avoid any miscommunication and assist in assessing pain trends in the ward.^{9, 10}

In summary, the perioperative management of deaf and mute patients is challenging and may result in adverse outcomes. Optimising the management by a thorough preoperative assessment, establishing effective communication, implementing objective assessment of pain and pain protocols and training the support staff will help in achieving a successful outcome.

Conflicts of interest

The authors have none to declare.