Exam 2 10/6 recovery - 11/10 pain assessment Flashcards
What is considered the recovery period?
the period of time between discontinuation of anesthetic to standing ( or maintenance of sternal recumbency)
General rule on when to extubate a pt.
Any species exceptions? Why?
After a swallow or cough usually,
Cats may be extubated a little earlier (due to propensity for laryngeal spasm in this sp.)
If regurgitation has occured what is different about extubation procedure?
Postural drainage position (nose low)
Extubate with cuff inflated or partially inflated after suction or swab of posterior pharyanx
What is monitored after extubation?
For how long?
TPR in all pts!!
+ Pulse ox in brachcephalics, upper/lower airway dz, pulmmonary pathology etc
+ BP in pt w/ hemorrhage, sepsis, hypovolemia, etc
every 5-10 min until able to hold head upright & maintain sternal recumbancy
Common complications during recovery
Bandages restricting breathing - watch tightness & modify if needed
Brachycephalics commonly develop upper airway obstruction! Have ET tube ready to reintubate if necessary in emerg.
Supportive care during recovery
active/passive warming as needed to maintain temp
Stimulate pt to incr LOC
- Change pt position* - roll legs under when switching laterals
- Auditory & tactile stim.*
Common recovery complications
Pain
Dysphoria
Hypo/hyperthermia
Hypoventilation
Hypoxemia
Prolonged recovery
Signs to recognize pain
TPR changes - usually incr
Vocalization - esp dogs
Posture/gait
Interaction with caregivers
Guarding of painful site
Behavior change
- Pain vs. dysphoria
- considerations when determining above
- opiod dysphoria = anxiety, nervousness, disorientation “bad trip”
if it is pain then pt will quiet with addtl opiods (pain control)
if it is dysphoria then pt will become more distressed w/ opiods!
- What has been given
expected level of pain for procedure performed
Pt temperment & breed - northern breeds seem more susceptible to dysphoria
surgical site pain - palpate gently, reaction suggests pain vs dysphoria
consequences of hypothermia
Short term:
incr O2 demand, prolonged recovery, discomfort
Long term: delayed healing, infection
strategy to Ddx pain vs dysphoria
admininster short-acting opiod (e.g. Fentanyl)
worse? = likely dysphoria
better? = likely pain
Alpha-2 agonist ► treats dysphoria & pain
Aceprom
Benzodiazepine
Opiod antagonist ► Butorphanol (mu antagonist) will maintain some analgesia (agonist & kappa receptor
Naloxone - must titrate carefully to avoid severe pain by removing opiod analgesia!
prolonged recovery rule outs
hypothermia
hypotension
hypoglycemia
electrolyte derangements
anemia
hypoventilation a/o hypoxemia
drugs
neurologic disease: pre-existing, anesthetic related
Cats esp. - blindness, stupor, coma - d/t cerebral hypoxia
avoid mouth gags in cats - compromise cerebral arterial blood flow
Whats special about equine recovery?
Horses will usually try to stand before they are physically capable!
- Most dangerous time in equine anesthesia* for patient AND personnel
- Potential for catastrophic injury*
Some complications in equine recovery that can be seen
Most similar to SA recovery complications
Pain, hypothermia, hypoventilation→ hypoxemia
Airway obstruction - horses are OBLIGATE nasal breathers
anemia, electrolyte disturbances
Myopathy / neuropathy
Types of equine recovery
Free recovery
Assisted recovery
Types of equine assisted recovery
“Hand”
Ropes inside stall
Ropes outside stall
Sling
Pool
Sedatives in equine recovery
Triple drip recovery usually rapid & smooth
Need sedative for smooth recovery from gas anesthesia
Alpha-2 agonist - Xylazine or romifidine preferred - detomidine & dexmedetomidine may cause ataxia
+/- Acepromazine - healthy anxious or high strung pts
How to tx pain in equines
NSAIDs
Alpha-2 agonists
Butorphanol
Morphine/Meperidine
Ruminant recovery
- Usually smart - don’t try to stand before able to*
- complication similar to SA plus:*
Regurgitation common +/- aspiration
Bloat
If your total ear canal ablation (TECA) pt woke up vocalizing & struggling, what would be an appropriate response?
a. Give naloxone
b. Give hydromorphone
c. Give buprenorphine
d. Give dexmedetomidine
e. B or D
Give hydromorphone or dexmedetomidine
What are some consequences of hypothermia
a. discomfort, poor healing, infection
b. rapid recovery
c. increased O2 demand
d. A and C
e. all of the above
a. & c.
discomfort, poor healing, infection & incr O2 demand
What would be some differentials for prolonged recovery in a horse
a. hypothermia
b. anemia
c. myopathy
d. hypocalcemia
e. all of the above
all of the above
hypothermia, anemia, myopathy, hypocalcemia
Which sp is considered to generally have a higher mortality rate, cats or dogs?
Cats (.24% vs.17% dogs)
when you take a pt. hx, what are the most common medications that we should be concerned about?
Heartworm prevention (more or less risk depending on location)
Diuretics (concern for hypovolemia, electrolyte imbalances)
ACE inhibitors, Ca-channel blockers, ß-blockers (concern for unresponsive hypotension 2° to anesthetics)
Anti-epileptic agents (may cause additive sedation)
Important things to ask SA owners when taking hx
Any signs of systemic disease? ESP. related to cardiac & pulmonary
“Any coughing, exercise intolerance?”
“Any previous blood transfusions?”
Dogs: 1st transfusion “free”, after 5-7 days develop antibodies, then must be typed & crossmatched
“Any previous anesthesias? Problems?”
How would signalment play a role in anes. safety?
Age: pediatric/geriatic pts have specific considerations
Gender/Repro status: pregnancy highest concern
Breed: many considerations
What are some specific dog breed concerns/considerations for anesthesia?
Sighthounds:
significantly prolonged recovery w/ thiobarbiturates⇒Avoid in these breeds
longer recoveries w/ propofol & alfaxalone also
Boxers:
Possible sensitivity to acepromazine
Brachycephalic breeds:
Brachycephalic airway syndrome
- You want them to go under as quick as possible & recover as quick as possible*
- preoxygenate if possible*
probably will need smaller ET tube than for size
monitor closely, keep O2 on until extubated, extubate as late as possible & be ready to reintubate!
Small breeds:
tracheal collapse - longer ETT available (to reach carina) in case
similar considerations as for brachcephalics
Why is documentation important
Avoid lawsuits based on percieved poor pre anesthetic eval.!
What are premedication considerations for dogs & cats?
Usually opioid + sedative IM before catheter
if IVC present can premed IV before induction
Opioid options: pure mu agonist vs partial (buprenophine) vs agonist-antagonist (butorphenol)
choose base on pt & proceedure
Which mu agonists are LEAST likely to cause vomiting?
fentanyl
methadone
When wouldn’t you really want vomiting?
incr. IC or intraocular pressure
pt unable to protect airway (laryngeal paralysis, decr ment.)
megaesophagus, etc
What are some non-anesthetic premeds?
H1 antihistamine = diphenhydramine - MCT removal (histamine → vasodilation, leaky vessels)
NK1 receptor antagonist = maropitant - given 30 min pre opioid to decr risk of vomiting
Dog & cat sedative options:
Acepromazine: mild-mod sedation, _Hypotension!_ - save for systemically healthy pts & use low dose (NOT LABEL!)
Dexdomitor: marked sedation, hypertension, reflex bradycardia, decr CO - save for systemically healthy pts
Benzodiazepines: not very sedating in healthy dogs (occas. excitement), may cause sedation in young, old, sick pts
CV & resp sparing! (minimal effects)
Premeds/anes for aggressive dogs
Owners should give informed consent
Pole syringe/door restraint
IM ketamine, telazol or alfaxalone combo w/ alpha-2 agonist & opioid!
Alpha-2 combo w/o anesthetic drug may be dangerous (unexxpected arousal)
What are the consideration for use of premed anticholinergics (antimuscarinics)?
Pts w/ pre-existing high vagal tone:
Brachycephalics, ophthalmic dx
Puppies:
dependent on norm HR for adeq CO
Procedures that may cause incr vagal tone
Don’t use w/ alpha-2 agonist unless low BP is documented!
d/t Reflex bradycardia from vasoconstriction→hypertension
What are some options for dog induction meds?
Propofol
Alfaxalone
Ketamine + benzo (midazolam or diazepam)
Etomidate + benzo
Considerations for dog induction with Propofol, Alfaxalone, Etomidate
Titrate to effect
give slowly - 1/2 calculated dose over 10-15 sec, evaluate then sm. boluses until intubatable
considerations for dog induction with ketamine
high therapeutic index
always give with a benzo (either same syr or benzo first)
longer onset than other induction agents
Considerations for dog intubation
Use laryngoscope
sterile lube to ETT cuff
easiest spp to intubate
brachycephalics can be more difficult d/t long soft palate
advance tube to thoracic inlet ONLY
What are anesthetic mainenance agents for dogs
Inhalant anesthetics:
iso, sevo most common
Injectables (CRI):
- propofol, alfaxalone*
- NOT etomidate d/t adrenal suppression*
Adjunct drugs that can be used as CRIs:
Opioids (fentanyl most common)
- lidocaine*
- ketamine*
- benzos*
What is the common rate for anesthetic IV fluids for CV support?
10 mL/kg/hr
Use balance, isotonic crystalloid fluids
How to tx anesthetic hypotension in dogs
Fluids first!
then if needed dopamine, dobutamine or ephedrine most common in relatively healthy pt
considerations of regurgitation in dogs with anesthesia
COMMON in dogs (not in cats)!
can cause esophageal damage
Aspiration - can be “silent”, causes cheical irritation & pulmonary edema
Prevention:
Proper ETT cuff lube & inflation
In high risk pts can use:
- PPIs - Omeprazole or esomeprasole prior to anes.
- Prokinetic drugs - metoclopramide or cisapride
On to cats… why are they special?
more difficult to anesthetize
more difficult to intubate
More likely to be hypotensive during
anesthesia than dogs at similar depth
More likely to be hypotensive during
anesthesia than dogs at similar depth
What are important considerations when getting hx for cats?
Cats hide disease well, often until it is advanced
Have to ask the right questions!
Cats will generally not cough except with asthma (don’t
try to identify heart disease by asking about a cough)
Exercise intolerance generally not appreciable
Ask about sleeping patterns, changes in jumping or general
activity, increased respiratory rate or effort, decreased
appetite, increased drinking and urination (how often
changing litter), vomiting etc.
Outdoor vs. indoor is important in relation to infectious
disease and trauma risk
Cat breed anesthetic considerations
Maine Coon – hypertrophic
cardiomyopathy (HCM)
Anesthetic-associated death d/t
fatal arrhythmia
Post-anesthetic congestive heart
failure - d/t drugs (ketamine or telazol)
and/or stress
_If a murmur is detected in a Maine Coon, a cardiologist
consult before elective anesthesia should be strongly
recommended (or required) to help identify the level
of risk and formulate an appropriate anesthetic plan_
*Remember cats can have HCM w/o auscultable murmur!!
Cat premedication considerations
Similar options as for dogs
Certain mu-agonist opioids preferred but all may be used
safely
Oxymorphone and methadone preferred over morphine or
hydromorphone
Fentanyl often used as CRI intra- and post-operatively for
analgesia
**Buprenorphine results in good visceral analgesia** and can be given transmucosally (TM) by the owner at home
All opioids can cause post-operative hyperthermia in cats.
Sedatives:
both acepromazine & dexmedetomidine provide good sedation - dexmedetomidine causes vasoconstriction → difficult IVC placement
Benzos don’t provide good sedation & may cause excitement - (better IV at time of induction)
