Nickel Sensitivity in Knee Arthroplasty
Pre-assessment is conducted by the nurse and it’s done on all patients together with an assessment of metal allergy cases (Kappe et al. Description During the surgery, the nurse in charge has the responsibility of determining the patient’s allergy conditions before the patient goes to the theatre. The Perioperative group also holds a meeting before going to the surgery where they discuss vital information that pertains every patient who appears on the surgical list on that day. The case being assessed involves a 72-year-old woman who came for Total knee arthroplasty and her status about nickel sensitivity was unclear. During the period of pre-assessment, the patient withheld the information about her nickel sensitivity however on the day of performing the surgery the patient disclosed of her nickel sensitivity (Gölz, Papageorgiou and Jäger, 2015).
To start with the miscommunication between the teams involved in the pre-assessment should not have happened as this resulted in the history of the patient's sensitivity to nickel not taken into account. The team was not thus well prepared to handle nickel hypersensitivity. However, there was some keenness since during admission this information was determined and directed to the anesthetist accordingly. Also even after the information about the patient's sensitivity to nickel was produced, the surgeon ignored and authorized the procedure to continue as normal. This is indicative of negligence and lack of evidence-based treatment since no investigation was done to confirm it. From the exposure time to the time the first rash appears it is usually 12-120 hours and this can go for up to 4 weeks.
For a nickel sensitivity to occur three simultaneous situations or conditions has to happen: Direct contact of skin and the substance that is releasing the nickel, prolonged contact of the skin and the substance releasing nickel and release of sufficient amounts of nickel into the skin enough to cause a skin reaction. The pathophysiology of nickel sensitivity and allergy is subdivided into induction and elicitation phases. Induction phase represents the most critical phase that is also called the immunological event and it’s when the skin comes into contact with nickel and it results in presentation of antigen to the T-cells and then there is T-Cell cloning. The nickel cation Ni++ has very low molecular weight and it’s a hapten hence it easily crosses through the stratum corneum.
Nickel is the most metal sensitizer among humans and it’s followed by cobalt and the chromium. If the implant is allergic it should be removed and should be replaced with those that will not cause hypersensitivity, for instance, Zirconium alloy that is oxidized or uses titanium –niobium. Patient experience in relation to nickel sensitivity When nickel come into contact with any biological system, there is corrosion and this electrochemical reaction results in the formation of ions of these metals and these ions form ternary complexes with the native proteins and in the process activates the immune system. Allergy presents with signs such as itching, redness, localized eczema, and pruritus. Any orthopedic implant results in dermatosis and exclusion of deep infections (Ford et al.
The patient as a result of them being sensitive to nickel, they developed a macular popular rash that was accompanied by itching especially on the places that came into contact with the nickel immediately after the operation. The patient needs to be involved in the decision making process pertaining their health and they have a right to every detailed information pertaining their health. They should be educated on every step they will undergo in the course of their treatment and be told if there is any precaution that is missing for instance in this clinical case the patient was not aware they were nickel sensitive and that doctors had ignored that fact and exposed the patient to avoidable reactions to nickel.
The experience for the patient was not pleasing as the risk is high and though the benefit of carrying out the operation may outweigh the risks some of the risks are avoidable by engaging the patient and being keen and taking precautions as per the stipulated requirements when dealing with such conditions. Metal hypersensitivity presents with symptoms such as swelling, rashes and also the pain. However, in the clinical case detailed these tests were not available hence no metal hypersensitivity for the patient was performed. Staff experience The medical staff who were taking care of the patient had a poor communication breakthrough. Communication with the patient was not effective as a misrecognition of nickel sensitivity from a patient and especially on a serious operation should not happen.
The theatre nurse should have detected such error before since it’s vital to the patients’ health. Communicating well with the patient is very important as this would help realize some more hidden information that could be detrimental if not unleashed. Any medical staff should strive to be knowledgeable in their field and be ready to question where there is no justice or negligence of duty and report to the necessary authority and stop such operations from happening. In the hospital, there is a sensitivity policy that governs on what should be done if cases of nickel sensitivity are reported and especially where knee replacement therapy is involved. Not Every patient who had nickel sensitivity reactions was advised to do a patch test instead some were advised to see a dermatologist if they were to undergo joint arthroplasty and they were to be given Titanium prosthesis.
However, it is very expensive and thus should be used with caution and only right patients should be advised to do it (Ozzie and Ozzie, 2018). Conclusion and recommendations In conclusion, this area of metal hypersensitivity, especially to nickel, have limited knowledge pool and insignificant clinical guidance and there is no evidence-based decision making. These events may have happened in practical, personal areas or even when learning. The cycle involves Description stage where one gets to tell what happened in details; Feelings that illustrates what one was thinking or feeling; Evaluation that determines which areas were good and which were bad; Analysis that involves determining the sense that can be made out of the situation; Conclusion that determines what else would have been done and finally The Action plan that determines the course of action in case something else like that happened.
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