L4: Pre- and postoperative care Flashcards
Anesthesia-related mortality
It’s highest for dogs and cats in postoperative period. Next risk is maintenance.
Anesthesia-related mortality in cats
Risk is 2x higher than in dogs. Possibly due to small size (hypothermia, overhydrating), uncooperative behaviour, prone to laryngospasm, Sensitivity to local anesthesia drug toxicity, reduced glucoronidation (slower drug metabolism)
ASA categories amount
5
ASA I
Apparently healthy
(mild periodontal disease, patellar luxation…)
ASA II
Mild systemic disease (Neonatal or geriatric animals, compensated cardiac disease, small tumors)
ASA III
Severe systemic disease (Chronic cardiac disease, fever, dehydration, cachexia, anemia)
ASA IV
Severe systemic disease that is life threatening (Heart failure, renal failure, hepatic failure, severe hypovolemia)
ASA V
Moribund; patient is not expected to live longer than 24h without surgery (endotoxic shock, multiorgan failure, severe trauma)
Goal of preoperative care
Planning for and anticipating complications is necessary to minimize the chance of adverse events
What details is included to preoperative care (6)
- Thorough anamnesis
- Full clinical examination
- Laboratory data
- Patient stabilization
- Determination of surgical risk
- Client communication
Have to be ready with medicines, calculations!
Anamnesis vitae includes
Basic information (species, breed, age, gender…) & lifestyle (diet, exercise, environment…)
Anamnesis morbi includes
-Reason for surgery
-Clinical signs and duration
-Past medical problems and treatment
-Current medical problems and treatments
-Prior anesthesia (used drugs, complications and recovery)
Why breed is important in anamnesis?
Anatomical differences and genetic predispositions have to be taken into consideration
Anemnesis of brachycephalic breeds
-Small hypoplastic trachea, elongated soft palate, stetonic nares
-Laryngeal mm prone to swelling
-Predisposition to gastroesophageal reflux
-Increased tone of n. vagus
-Higher risk of hypoxia
Anamnesis of toy breeds
-Hypothermia
-Catheter placement
-Questionable accuracy of monitors
-Intubation is more difficult
-Accuracy of drug dosages
-Hands-on assessment limited during anesthesia
Anamnesis of giant breeds
-Lower drug dosages required
-Considered geriatric at younger age
-Patient handling more difficult
Mutation of MDR-1 gene
In herding breeds, causes prolonged effect of some drugs
Why age is important in anamnesis?
Pediatric and geriatric patients are at a higher risk.
Risk of pediatric patients
-Immature organs and defence mechanisms
-Prone to hypothermia, hypoglycemia, regurgitation
-Blood loss more dangerous
Risk of geriatric patients
-Reduced response to hypercapnia, hypoxemia
-Slower metabolism and healing, decreased organ function
-Prone to hypothermia, regurgitation
Clinical examination of cardiovascular system (3)
-Heart auscultation
-Pulse (peripheral, kukaan ei oikeesti tee tätä käytännössä töissä)
-Mucous membranes
Clinical examination of respiratory system (4)
-Breathing patterns and noises
-Lung auscultation
-mucous membranes
-Palpation of trachea
Hydration status (3)
-Mucous membranes
-Turgor
-Eyes
What things are included to clinical examination? (8)
1.Cardiovascular system
2.Respiratory system
3.Hydration status
4.Gastrointestinal and urinary system
5.Integumentary system
6.CNS
7.BCS
8.Temperature
What to recommend for diagnostic tests
Packed cell volume, total protein, glucose, urea
Patient stabilization
-Should be done to all patients prior to sedation if possible
-Hemodynamics, respiratory function, hydration status
What to consider about sedation and analgesia? (5)
- Choise of drugs and its several factors
- Optimal pain control during and after anesthesia
- Multimodality
- NSAIDs and opioids usual
- Familiar protocol usually best
Oxygenation
Pre-oxygenation usually warranted to prevent hypoventilation and hypoxemia. Started before induction and intubation. Administration continued after intubation.
Thermoregulation
Hypothermia is very common complication => hypoxia, prolonged recovery, increased infection risk, worse cardiovascular parameters. Warm infusions are not so effective. Warming should be started as soon as possible.
Why infrared light is not recommended without a folium blanket?
May promote inflammation and burn skin!
Purposes of intraoperative fluid management? (3)
- Maintenance of hemodynamics
- Maintenance of the catheter
- Amortization of fluid and blood loss
Starting doses of fluids?
5ml/kg/h for dogs
3ml/kg/h for cats
reduce 25% each hour, unless blood or fluid loss
Most often used fluids?
Ri-Lac or Hartmann’s solution (not NaCL 0,9%)
Why positioning is important?
-Intubation, catheterization
-Procedure, monitoring
-Well-being of the patient
What belongs to postoperative care? (6)
- Pain management
- Nutritional management
- Wound care
- Care related to procedure (immobilization etc)
- Other care possibilites
- Home care with good instructions
Postop pain management
Better options in the clinic. Keep in the clinic until proper analgesia. Home: NSAIDs, tramadol, fentanyl/lidocain patch, gabapentin…
Patient has to be closely monitored until (8)
- Has been extubated
- Is laying on sternum, head elevated
- Is able to swallow, has normal ocular reflex
- Has a strong and regular peripheral pulse
- Has an oxygen saturation of >94%
- Has no suspicion of upper airway obstruction
- Has effective analgesia
- Has no evident bleeding
Wound care principals (7)
*Owner must be instructed in detail
* Wound care should be provided daily (usually up to 14 days)
* Wound exudate should be removed
* Cleaning with physiological solution is recommended
* Wound gels may be applied
* Suture material usually removed after 7-14 days
* A follow-up is also warranted in case an intradermal pattern was used
