How do we manage recovery from anaesthesia and care for animals in the post operative period.

Question 1

Steps to get patient into recovery.

Answer 1

• Prep for end of anaesthesia.
  – Prep to reduce VA (or IV agent).
  – Turn up to 100% oxygen if using nitrous oxide.
  – Ensure bandages placed / wounds clean / additional procedures complete.
  – Ensure analgesia in place.
• End of anaesthesia.
  – Turn off all the anaesthetics.

Question 2

Ideal recovery environment.

Answer 2

• Safe and secure.
• Ideally purpose built – but not always possible.
• Well ventilated.
• Warm.
• Accessible and easy to observe patients.
• Close proximity to clinical supplies i.e. O2, catheters, swabs, emergency kit, etc. and staff.

Question 3

Common types of airway device.

Answer 3

• Supraglottic airway device (V-Gel).
• ETT.
• LMA (Laryngeal Mask Airways).
• Face mask.

Question 4

Management of the airway and prep for extubating.

Answer 4

• Loosen / untie ties on ETT ready to remove.
  – Do not do this if about to move the patient.
• Deflate cuff when close to extubating, not too soon.
• Spp dependent on what next.
  – Dogs and rabbits: watch for signs that laryngeal reflexes returning e.g. swallowing.
  Watch to see if other reflexes returning and/or spontaneous movement.
  – Cats: Have v sensitive larynxes so danger of laryngospasm if wait for them to swallow w/ ETT still in. Need to extubate before this point, when you get ear flick and blink.

Question 5

Extubate.

Answer 5

• Do not wiggle the tube.
• Remove smoothly w/o damaging airway on way out – remember it is curved!
• Watch your fingers.
• Remove to early, patient has unsupported airway.
• Remove too late, patient may bite tube / damage airway / get distressed / develop laryngospasm (cats).

Question 6

1. Give example that may need later extubation.
2. Considerations.

Answer 6

1. Brachycephalic dogs after airway surgery.
2. Careful monitoring.
   Patients tolerate remarkably well.
   Not to be done in cats due to risk of laryngospasm.

Question 7

1. How should the tongue be positioned before extubation?

Answer 7

1. Pull tongue put of the side of the mouth so that it does not obstruct the airway. And more pleasant for patient if wet the tongue if it feels dry. Give tongue a gentle tug later on in recovery if it seems like they have it stuck outside the mouth so they can regain the function of it to pull it back in.

Question 8

Next stages post extubating.

Answer 8

Monitor to see if they can lift own head.
Wait for them to assume sternal recumbency.
Wait for them to be able to stand.
Then full recovery with no signs of sedation / ataxia.

Question 9

What should we monitor in the recovery phase of anaesthesia?

Answer 9

TPR.
Quality of recovery.
Pain / analgesia.

Question 10

Temperature monitoring.

Answer 10

ESSENTIAL!!!
Lubricated digital thermometer.
Can get digital rectal probes for continual measurement but dept on patient tolerance.
Frequency of measurement somewhat depends on individual case.

Question 11

1. Hypothermia effect on the heart.
2. Hypothermia effect on blood.
3. Hypothermia effect on recovery.
4. Hypothermia on O2 requirement?

Answer 11

1. Bradycardia, cardiac arrhythmias – atrial fibrillation at <30C, ventricular fibrillation at 24-28C.
2. Impaired coagulation and wound healing.
3. Slower recovery due to prolonged duration of drug action.
4. Shivering increases O2 requirement.

Question 12

How do we minimise hypothermia?

Answer 12

Warm from time of premedication.
Warm throughout peri-operative period.
- Insulation.
- Warm fluids.
- Heat & moisture exchangers and careful selection of breathing system.
- Care with prior clip and skin prep.
- Heating devices.
- Warm environmental temperatures.

Question 13

Pulse monitoring during recovery.

Answer 13

Look at MMs for colour.
CRT (ideally <2 sec.)
GET GOOD AT FEELING PERIPHERAL PULSES!!
Can use pulse ox but not often practical beyond a certain point in recovery.
May also need/want to auscultate the chest.
Carry out ECG if required.

Question 14

Respiration in recovery.

Answer 14

Patient needs patent airway.
- Check for oral obstruction (saliva, blood vomit).
- Anatomical obstruction (e.g. neck kinked as head stuck in corner of cage etc).

Put patient in head down position if worried about inhalation of saliva/blood/vomit – if doing this with an open cage door, need to be w/ patient at all times!

Remove water bowl – don’t want semi conscious patient to drown in it.

Count RR (bpm).
Note pattern. (deep v shallow, abdo v thoracic).
May need chest auscultation.
May need to supplement O2 if worried.

Question 15

Types of O2 supplementation.

Answer 15

O2 cage / tent (smaller patients only).
Face mask – may not tolerate.
Nasal O2 – may not tolerate.
Flow by.

Question 16

1. Aim for quality of recovery.
2. What should monitoring be based on?
3. Risk associated with excitement in recovery.
4. Horse recovery.

Answer 16

1. Calm and stress free.
2. The patient, if they are ‘at risk’, and the type of procedure.
3. Patient can injure him/herself or staff so suitable cages / boxes needed and need to remove obstructions, consider sedation.
4. Needs to be controlled.
   Risk of injury.
   Think about whole environment

Question 17

Definition of pain from the International Association for the Study of Pain.

Answer 17

An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Question 18

Points about pain.

Answer 18

• Always a personal experience that is influenced to varying degrees by biological, psychological and social (bio-psycho-social model) factors.
• Pain and nociception diff phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  – Nociception is the process by which noxious stimulation is communicated through the peripheral and CNS.
• Individuals learn the concept of pain through experience.
• A person’s report of an experience of pain should always be respected.
• Pain usually serves an adaptive role but may have adverse effects on function and social and psychological well-being.
• Verbal description is only one of several behaviours to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

Question 19

Acute pain.

Answer 19

Usually comes on quickly.
Doesn’t last forever.
Caused by a specific event.
Has a purpose.

Question 20

Chronic pain.

Answer 20

Lasts for much longer – 3-6+ months.
Pain that outlasts normal tissue healing.
Not so easy to manage.
Not so much of a purpose.

Question 21

Events after incision.

Answer 21

• Local immune cells will start to release prostaglandins – important in inflammation.
  This process is the conversion of the noxious stimulus to an electrical signal = transduction
• Sensory nerve fibres all over the body will respond to prostaglandins and carry the signal to the dorsal horn of the Spinal Cord = transmission.
• In dorsal horn of spinal cord, message / signal carried further up via area called ‘spinothalamic tract’ = modulation.
• Signal then carried further up the spinal cord, through the brainstem and into the brain.
  Signal stops at the thalamus.
  Signal now in the brain and will be perceived by the person / animal.
  = perception.

Question 22

Behavioural signs of pain.

Answer 22

• Differs in prey vs predator.
• Inappetence.
• Reluctance to walk/move/jump/stand.
• Difficulty in mobility.
• Vocalisation.
• Panting.
• Lip-smacking.
• Yawning?
• Aggression.
• Sleeping more.
• Reacting badly to being touched.

Question 23

Physiological signs of pain.

Answer 23

• HR.
• RR.
• Temp.
• BP.

Question 24

One dimensional scales of pain assessment examples.

Answer 24

• Simple descriptive scales.
• Numerical rating scales.
• Visual analogue scales.

Question 25

Multidimensional scales of pain assessment

Answer 25

• Composite scales.
• Grimace scales.
• Behavioural scales.

Question 26

Other factors, apart from pain, that may contribute to patient discomfort.

Answer 26

Full bladder.
Cold.
Too hot.
Wet bedding.
Tight stitches.
Clipper rash.
Need to defecate/urinate.
Fear/anxiety.

Question 27

IV catheter care.

Answer 27

Flushed, patent, fluids running etc.
Properly covered and suitably padded.
If removing, ensure to place pressure on area to prevent haematomas.

Question 28

Checking a wound or surgical site.

Answer 28

Looking for bleeding / swelling etc.
If patient is interfering w/ wound, may need to dress wound or use BC/MPS.
Check that nothing swelling due to over-tight dressings.
Check the consent form for any other procedures or requests.

Question 29

Basic nursing care.

Answer 29

Clean, dry, warm, quiet.
Toilet.
Water and food when appropriate.
TLC.

Question 30

Post op feeding.

Answer 30

Feed when awake / able to stand and able to swallow, unless:
- GI surgery.
- Sedation / CRI’s.
- Follow up imaging.

Remember patient has not eaten for some time.
Bland, soft food.
Little and often.
Small mammals may need assisted feeding.

Question 31

Recording of all post op data.

Answer 31

• On specific continuation sheet (hospital record) or on back of anaesthetic record card.
• Map trends as during anaesthesia.
• In case of adverse event, can demonstrate that care was provided.