Other Assorted Topics: Recovery, Analgesia, Environmental Considerations, Urine Output, Regurg

Question 1

Regurgitation

Answer 1

• Most frequently documented perioperative complication
• Documented risk in patients without predisposing disease reported between 0.42-5.5%
• Risk of GER reported range between 16-60%

Question 2

Patients at Increased Risk for Regurgitation

Answer 2

o Increased pressure on stomach – space occupying abdominal masses, c sections
o Patients with hx of regurgitation/vomiting
o Patients with substantial gastric contents – fluid accumulation secondary to GDV, FB, not appropriately fasted
o Patients with ME – MG, chronic GER untreated hypothyroidism, lar par thymoma
o Multiple changes in recumbency
o Trendelenburg

Question 3

Trendelenburg?

Answer 3

Head TIPPED DOWN

Question 4

Reverse trendelenburg?

Answer 4

Head RAISED UP

Question 5

Preoperative pharmacological management of regurg

Answer 5

o Metoclopromide CRI
o Maropitant – for vomiting and nausea; does not prevent regurgitation!

Question 6

Positioning. Patient Handling

Answer 6

o Secure airway with patient in sternal recumbency, head elevated – tied in, cuff inflated
o Recover patient in sternal with head elevated
o Suction, lavage esophagus with water when regurgitation detected, prior to recovery

Question 7

Urine Output

Answer 7

Normal 1-2mL/kg/hr

Question 8

How anesthesia affects urine output

Answer 8

• Anesthesia: greatly reduces GFR, UOP (10x); further reduced by hypotension
• Prolonged hypotension, increased risk of AKI

Question 9

Clinical Indications for monitoring urine output

Answer 9

o Patients at increased risk of AKI/profound hypotension
o Septic
o Extensive rhabdomyolysis/pigmenturia
o Existing oliguria

Question 10

Monitoring during the post-anesthetic period

Answer 10

• CSU Study: 61% of ax deaths occur during recovery, CEPSAF: 50% of deaths 0-3 hours post ax
  o SpO2 – Avoid dead in the cage scenario
• Temperature

Question 11

Dysphoria

Answer 11

= Emergence delirium = substance induced agitation and hyperactivity as patient transitions from anesthesia to wakefulness

Question 12

How to distinguish pain from dysphoria

Answer 12

o Dysphoria gets better with time and consciousness, no change as surgical site palpated
* Palpate bladder

Pain worsened as consciousness progresses, reactive to sx site palpation

Question 13

Treatment Options for Dysphoric Patient

Answer 13

o Do nothing – wait
o Sedative; ace vs dexmed
o Take for walk to facilitate reorientation

Question 14

Three Categories of AEs with Anesthetic Drugs

Answer 14

1. ** Patient-experienced adverse drug reactions**
2. Adverse effects experienced by health, veterinary care providers exposed to anesthetic drugs, gases during performance of their daily tasks
3. Adverse environmental effects

Question 15

6 Types of Patient-Experienced Adverse Reactions

Answer 15

1. Dose related
2. Non dose related
3. Dose/Time Related
4. Time related
5. Withdrawal
6. Failure of Therapy

Question 16

Type A Patient ADR

Answer 16

Dose-Related
“Augmented”

Question 17

Type B Patient ADR

Answer 17

Non-Dose Related
“Bizarre”

Question 18

Type C Patient ADR

Answer 18

Dose related, time related

“Chronic”

Question 19

Type D Patient ADR

Answer 19

Time-Related

“Delayed”

Question 20

Type E Patient ADR

Answer 20

Withdrawal, “end of use”

Question 21

Type F Patient ADR

Answer 21

Failure of therapy, “Failure”m

Question 22

AEs experienced by health, veterinary care providers exposed to anesthetic drugs, gases during performance of daily tasks

Answer 22

o Acute exposure through accidental needle penetration, spillage of drugs
o SOPs in place instructing employees on how to limit exposure, proceed if exposure occurs
o Chronic workplace exposure to low levels of inhalant ax agents concerning –> questions exist about relative risk of toxicity (infertility, miscarriage, cancer, other chronic health problems)
o Low incidence of AEs, potentially long lag period btw exposure, expression of toxicity
o Difficult to study DT challenges/confounders of large epidemiological studies

Question 23

Environmental AEs

Answer 23

Desflurane = responsible for largest greenhouse gas emission (both CO2, halogenated compounds) during lifecycle
 15x iso, 20x that of sevo per MAC-hr basis

Concurrent use of N2O further increases emissions

Question 24

All Inhalants

Answer 24

eventual release as WAGs into atmosphere = largest contributor to GHG footprint, global warming potential

Question 25

GHG Potential/Impact Propofol

Answer 25

associated with propofol, many other injectable agents primarily related to production, consumption of fossil fuels needed to manufacture, deliver drugs