Exam 2 10/6 recovery - 11/10 pain assessment

Question 1

What is considered the recovery period?

Answer 1

the period of time between discontinuation of anesthetic to standing ( or maintenance of sternal recumbency)

Question 2

General rule on when to extubate a pt.

Any species exceptions? Why?

Answer 2

After a swallow or cough usually,

Cats may be extubated a little earlier (due to propensity for laryngeal spasm in this sp.)

Question 3

If regurgitation has occured what is different about extubation procedure?

Answer 3

Postural drainage position (nose low)

Extubate with cuff inflated or partially inflated after suction or swab of posterior pharyanx

Question 4

What is monitored after extubation?

For how long?

Answer 4

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

Question 5

Common complications during recovery

Answer 5

Bandages restricting breathing - watch tightness & modify if needed

Brachycephalics commonly develop upper airway obstruction! Have ET tube ready to reintubate if necessary in emerg.

Question 6

Supportive care during recovery

Answer 6

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.*

Question 7

Common recovery complications

Answer 7

Pain

Dysphoria

Hypo/hyperthermia

Hypoventilation

Hypoxemia

Prolonged recovery

Question 8

Signs to recognize pain

Answer 8

TPR changes - usually incr
Vocalization - esp dogs
Posture/gait
Interaction with caregivers
Guarding of painful site
Behavior change

Question 9

1. Pain vs. dysphoria
2. considerations when determining above

Answer 9

1. 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!

2. 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

Question 10

consequences of hypothermia

Answer 10

Short term:

incr O2 demand, prolonged recovery, discomfort

Long term: delayed healing, infection

Question 11

strategy to Ddx pain vs dysphoria

Answer 11

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!

Question 12

prolonged recovery rule outs

Answer 12

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

Question 13

Whats special about equine recovery?

Answer 13

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*

Question 14

Some complications in equine recovery that can be seen

Answer 14

Most similar to SA recovery complications

Pain, hypothermia, hypoventilation→ hypoxemia

Airway obstruction - horses are OBLIGATE nasal breathers

anemia, electrolyte disturbances

Myopathy / neuropathy

Question 15

Types of equine recovery

Answer 15

Free recovery

Assisted recovery

Question 16

Types of equine assisted recovery

Answer 16

“Hand”

Ropes inside stall

Ropes outside stall

Sling

Pool

Question 17

Sedatives in equine recovery

Answer 17

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

Question 18

How to tx pain in equines

Answer 18

NSAIDs

Alpha-2 agonists

Butorphanol

Morphine/Meperidine

Question 19

Ruminant recovery

Answer 19

• Usually smart - don’t try to stand before able to*
• complication similar to SA plus:*

Regurgitation common +/- aspiration

Bloat

Question 20

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

Answer 20

Give hydromorphone or dexmedetomidine

Question 21

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

Answer 21

a. & c.

discomfort, poor healing, infection & incr O₂ demand

Question 22

What would be some differentials for prolonged recovery in a horse

a. hypothermia
b. anemia
c. myopathy
d. hypocalcemia
e. all of the above

Answer 22

all of the above

hypothermia, anemia, myopathy, hypocalcemia

Question 23

Which sp is considered to generally have a higher mortality rate, cats or dogs?

Answer 23

Cats (.24% vs.17% dogs)

Question 24

when you take a pt. hx, what are the most common medications that we should be concerned about?

Answer 24

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)

Question 25

Important things to ask SA owners when taking hx

Answer 25

*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?"**

Question 26

How would signalment play a role in anes. safety?

Answer 26

**Age: pediatric/geriatic pts have specific considerations** **Gender/Repro status: pregnancy highest concern** **Breed: many considerations**

Question 27

What are some specific dog breed concerns/considerations for anesthesia?

Answer 27

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**

Question 28

Why is documentation important

Answer 28

Avoid lawsuits based on *percieved* poor pre anesthetic eval.!

Question 29

What are premedication considerations for dogs & cats?

Answer 29

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*

Question 30

Which mu agonists are LEAST likely to cause vomiting?

Answer 30

**fentanyl** **methadone**

Question 31

When wouldn't you really want vomiting?

Answer 31

incr. IC or intraocular pressure pt unable to protect airway (laryngeal paralysis, decr ment.) megaesophagus, etc

Question 32

What are some non-anesthetic premeds?

Answer 32

**H1 antihistamine = diphenhydramine -** MCT removal (histamine → vasodilation, leaky vessels) **NK1 receptor antagonist = maropitant** - given 30 min pre opioid to decr risk of vomiting

Question 33

Dog & cat sedative options:

Answer 33

**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)_***

Question 34

Premeds/anes for aggressive dogs

Answer 34

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)**

Question 35

What are the consideration for use of premed anticholinergics (antimuscarinics)?

Answer 35

**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*

Question 36

What are some options for dog induction meds?

Answer 36

**Propofol** **Alfaxalone** **Ketamine + benzo (midazolam or diazepam)** **Etomidate + benzo**

Question 37

Considerations for dog induction with Propofol, Alfaxalone, Etomidate

Answer 37

**Titrate to effect** **give slowly -** *1/2 calculated dose over 10-15 sec, evaluate then sm. boluses until intubatable*

Question 38

considerations for dog induction with ketamine

Answer 38

**high therapeutic index** **always give with a benzo** *(either same syr or benzo first)* **longer onset than other induction agents**

Question 39

Considerations for dog intubation

Answer 39

**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**

Question 40

What are anesthetic mainenance agents for dogs

Answer 40

**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*

Question 41

What is the common rate for anesthetic IV fluids for CV support?

Answer 41

**10 mL/kg/hr** Use balance, isotonic crystalloid fluids

Question 42

How to tx anesthetic hypotension in dogs

Answer 42

**Fluids first!** **then if needed dopamine, dobutamine or ephedrine most common in relatively healthy pt**

Question 43

considerations of regurgitation in dogs with anesthesia

Answer 43

**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

Question 44

On to cats... why are they special?

Answer 44

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

Question 45

What are important considerations when getting hx for cats?

Answer 45

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**

Question 46

Cat breed anesthetic considerations

Answer 46

**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!!**

Question 47

Cat premedication considerations

Answer 47

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)