Care of the recovering patient Flashcards
When does recovery start for an anaesthetic patient?
The moment that administration of an anaesthetic agent ceases - patients are vulnerable and should be consistently monitored to prevent problems
What is Broadbelt’s enquiry and what did it identify?
It was a study into perioperative fatalities in cats and dogs - it identified that 60% of all anaesthetic related deaths occur during the first 3 hours of the recovery period.
What are some reasons that may cause an anaesthetic related death of a patient in recovery?
- no dedicated recovery nurse
- reduced monitoring in recovery
- lack of anaesthetic support, often no supplementary oxygen available
- hypothermia
- premature extubation
What are some specific complications that could arise during recovery?
- upper airway obstruction
- hypoxemia
- hypothermia
- pain
- haemorrhage
- emergence excitement
What can cause emergence excitement?
Insufficient premed, extreme pain, long procedure, certain drugs such as ketamine, or anxious breeds such as Huskies or Staffies
What are some indicators of pain in the recovering patient?
Paddling, vocalisation, trembling, aggression, withdrawal
Describe the risk of upper airway obstruction for the recovering patient
May be due to regurgitation and vomiting due to lower pharyngeal tone, or laryngospasm in cats
Describe the risk of hypoxaemia for a recovering patient
Indicates low oxygen levels in the blood.
Monitored by SPO2, and perfusion parameters. Supplementary oxygen given via flow by, mask, tent or nasal prongs may be useful
What level should an SP02 reading be above?
More than 95%
Describe the risk of hypothermia to the recovering patient
Hypothermia is a key delay factor in recovery - shivering can increase oxygen demands by up to 500%
Describe the risk of pain to the recovering patient
A painful animal can be a danger to itself and veterinary staff. Analgesia should be sufficient and regular if required. Pain scoring should be done, and indications of pain noted
At what temperature does thermoregulatory shivering not occur?
Does not occur below 35 degrees Celsius
Describe the risk of haemorrhage for a recovering patient
May be internal, and increase risk of hypovolaemic shock, or external, from surgery wound or strikethrough bandage/dressing
What tool can be used to reduce the levels of risk following anaesthesia?
Veterinary checklists that outline the steps to be taken pre-during and post anaesthesia. They reduce the risk of human error and are excellent for succinct record keeping
What is the standard process for extubation?
Ideally the isoflurane should have been turned down gradually, and once the procedure has finished, turned off completely. The patient is then disconnected from the circuit, which is then flushed to remove any residual isoflurane, and can be repositioned into lateral or sternal recumbency. The tube can then be decuffed, and any debris or haemorrhage present in the mouth should be removed by swabbing or suction. The patient should receive fresh gas flow for ideally 5-10 minutes.
Reversal can be given, at discretion of the vet
The procedure then differs for dogs and cats, but in both species the end of the ET tube should be checked for blood or debris once removed
What is the specific extubation procedure for dogs?
The ET tube should be left in situ until the animal demonstrates the first sign of a gag or rejection reflex (the swallow or cough). The animal can then be transferred to a kennel
What is the specific extubation procedure for cats?
They should be extubated prior to swallowing and full sensation returning as they are prone to laryngospasm
How would a nurse assess to see if a patient could protect its airway adequately?
- mucous membrane colour should be pink, with a CRT <2s
- pulse ox reading of >95%
- RR should be normal and effort should not be shallow or laboured. Pattern should be normal
What is paradoxical breathing?
A sign of diaphragmatic dysfunction - the diaphragm moves in the opposite direction it should do when breathing
What is the specific procedure for extubation for brachycephalic breeds?
The ET tube should be left in situ until it is no longer tolerated - this means they may be sitting up, swallowing around it, or even mobile before it is removed. This is because the anatomy of these dogs means it is very easy for their airway to be obstructed
When should a brachycephalic breed never be extubated?
During periods of stimulation, as airway obstruction may occur when they fall back into unconsciousness
Why should cats be extubated prior to full sensation returning?
Because of the risk of laryngospasms
What signs indicate that a cat is ready to be extubated?
- an ear flick
- a strong palpebral reflex
- jaw tone
When can a patient in recovery be left alone?
If they have a normal TPR, with strong peripheral pulses, they are alert and able to lift their head, swallowing and with normal ocular reflexes. They must not be shivering, with body temp of at least 35C, be breathing freely and deeply, with normal MM colour and CRT of <2s. Effective analgesia should be on board
What are some specific requirements for the recovery area of a practice?
- somewhere where the patient can be under constant observation
- warm and quiet, with dimmed lighting
- well ventilated, to eliminate any residual volatile agent
- access to pulse ox and BP monitoring
- access to emergency drugs in case of patient crash
- access to supplementary oxygen and support
- access to airway suction in case of regurgitation or airway obstruction
What is the significance of the bladder for a patient under GA?
A full or distended bladder can contribute to post operative pain, discomfort and anxiety. It should be expressed (by applying pressure to the caudal abdomen) under GA to prevent this
What is the importance of positioning for patients in recovery?
They should be on comfortable, padded bedding, in sternal recumbency, although lateral recumbency is okay for patients with no respiratory complications. Patients should have their heads facing the outside of the kennel, with their head and neck gently extended, with the tongue pulled forward
Patients should not be placed on their surgical incisions if possible
Define ATELECTASIS
Complete or partial collapse of the enitre lung or lobe of the lung
What drugs limit tear production and for how long?
Many opioids, sedatives and volatile agents limit tear production for up to 36 hours
What is the ideal provision of oxygen for recovering patients?
It should ideally be provided until extubation occurs, although a minimum of 5-10 minutes fresh oxygen after turning off the vaporiser is a general requirement
What are important parameters to monitor in recovery?
Heart rate, respiratory rate, temperature, pulse pressure, mucous membrane colour and capillary refill time, blood pressure, demeanour
What can cause issues with thermoregulation during surgery?
- administration of sedative agents
- reduced muscle activity
- clipping
- cold prep solutions
- open body cavities and cool fluids
Define PHARMACOKINETICS
How the body affects a specific substance after administration
What are some side effects of thermoregulation issues for GA patients?
Affects pharmacokinetics (particularly MAC for volatile agents), reduced immune function, an increases the risk of post operative wound infections. Affects blood coagulation, and results in higher risk of haemorrhage. Metabolic rate is lowered, and oxygen demand is increased by shivering
What is the effect of ketamine on temperature in cats?
It is more likely to make them hyperthermic
Describe active warming
Involves the application of external heat to skin and peripheral tissues. Includes:
forced air warming (Bair hugger), heat mats, hot water bottles
Describe passive warming
Includes interventions to promote heat retention, and includes blankets, bootees or bubble wrap on extremities, reflective blankets, and raising the environmental temperature
What may cause a low respiratory rate for recovery patients?
They may be hypothermic, or those who are still deeply anaesthetised
What may cause a high respiratory rate for recovery patients?
May be due to pain or respiratory restrictions. Patients may have trouble expanding their chest if it is bandages, if there is chest fluid, or a pneumothorax
What can bradycardia stem from?
Hypothermia or drug administration, such as from alpha 2 agonists or opioids
In what kind of patients are arrythmias more commonly seen in, in recovery?
They are not common but may be drug induced, or secondary to existing heart conditions, GDVs or trauma
What is pulse pressure?
The difference between the systolic and diastolic pressure, which gives some idea of tissue perfusion
Where should a strong peripheral pulse be able to be felt?
In the dorsal pedal artery in the dog. It may be more difficult to feel in cats or hypothermic animals. If not palpable, check the femoral artery
What could a poor peripheral pulse indicate?
Intense vasoconstriction, due to hypothermia, hypovolaemia, or possibly pain
At what rate are IVFT boluses usually given?
10ml/kg, but always at vet discretion
What should be done if manual checking of CRT is inaccurate?
Use a pulse oximeter. Any concerns with SPO2 reading or CRT should mean the patient receives supplementary oxygen
What is good practice for the frequency of checks in recovery?
Checks to be performed every 10 minutes for the first hour, increasing to every 30 minutes or hourly thereafter, depending on the animal, its progress and the procedure performed
Describe excitement in recovery
Not common, but may be seen in animals who were not sufficiently sedated prior to induction. Prevalent in some breeds such as Huskies or Dobermanns, The animal can injure themselves, the staff, and upset other patients. It may be due to pain, or it may be drug induced
What breeds are particularly prone to an excitable recovery?
Huskies, staffies, Dobermanns
What are methods of recognising pain in a recovering animal?
- vocalisation,
- facial expressions
- self trauma
- depression/hiding
- aggression
- restlessness
When patient is fully awake, pain scoring
How often should pain scoring be performed?
Every 30 minutes during recovery, especially before analgesia is due and 15 minutes after as well
What is important to remember when pain scoring a patient?
- the type of drugs given and whether they have been reversed
- some systems have a lameness score which should be disregarded if the patient is non-ambulatory
- many validated pain scoring systems have a threshold at which analgesia should be given
- more sections in a pain scoring system is generally more holistic
- pre procedure pain scoring can provide a baseline
Give some examples of validated pain scoring methods
The Glasgow pain scoring system, the Botucatu Multidimensional Composite pain scale for cats, the Newcastle grimace scales for rabbits and rodents
What should be recorded when giving drugs to a patient?
- name and strength of drug given
- amount given and when
- who gave the drug
- who authorised the giving of the drug (vet)
- roue of administration
- if CD, recorded in the relevant book
What are some key aspects that an owner should consider at home following surgery?
Depression, panting, whining, inappetence, bowel movements, nutrition
Describe patient depression in longer term recovery
Patients are likely to be lethargic immediately after and for up to 24 hours after surgery as the effects of sedatives and opioids wear off. Restriction of normal activities such as playing, walking etc, or the addition of a cone to aid wound healing can also trigger depression
Describe whining in patient longer term recovery
May be a combination of anxiety, restlessness, pain or frustration. The patient can be enriched to help prevent this - a nurse can suggest options
Describe panting in longer term recovery
May be anxiety, pain or hyperthermia. Anxiety should ease once the patient is back in their normal routine at home, pain should be assessed by the nurse at post operative checks and by the owners at home. Analgesia should be given or extended accordingly
Describe inappetence for longer term recovery
A patient may be nauseous or inappetent for the first 12-24 hours following surgery. Owners should be made aware of this and not panic, but be advised to give frequent, smaller meals, of possibly bland food. Prolonged inppetence should be reported to the practice
Describe bowel movement considerations for a patient’s longer term recovery
GI systems can slow following surgery both because of the affect of the drugs given, and the fasting period prior to surgery. Urination should be normal, particularly if the patient received IV fluids throughout their surgery
Describe nutrition importance for longer term recovery
Food and water is offered to patients in recovery when they are conscious and able to sit up, and move around. It aids normothermia and return to normal digestive function, and aids glucose levels. Hospitalised patients do not have a higher RER than regular patients so should be fed a normal diet, and overweight patients should not have food withheld
What is ‘Phase 1’ of recovery
Immediately after surgery and up to about 48 hours after - fluid circulation is very important, so the intestinal tract has sufficient nutrients. Recuperation nutrients such as glutamine, taurine, arginine and omega 3/6 fatty acids should be provided
Describe Phase 2 of recovery
Lasts up to 14 days post surgery and focuses on patient calorie intake, ensuring it is sufficient
Do hospitalised patients have a higher energy requirement?
No, their RER is the same
What is the Garcia effect?
An aversion to a new food that has been introduced while a patient is ill. New foods should not be introduced while a patient is ill, and should be done over 7-10 days at home
What are specific recovery concerns for smaller patients?
Hypo and hyperthermia (particularly due to rabbits and g pigs lack of sweat glands), ileus for rabbits
Which bedding type is often unsuitable for small post operative patients?
Wood shavings, or other bedding that can easily stick to the wound
Describe some specific rabbit post operative concerns
If a rabbit has not begun to eat 4-6 hours post surgery, supplemental nutritional support is necessary to prevent ileus, hepatic lipidosis and death. Anorexia may be due to stress or pain so these should be effectively managed.
