Perioperative Evaluation, Patient Prep, and Post- Operative Care Flashcards
What is the importance of pre operative assessments?
• Consider it as pre-surgical planning
• Provides a solid foundation for the surgical procedure
• Gives baseline physiologic data for the patient
• Facilities assessment of disease and the relevance to the surgery
What does pre-operative patient evaluation include?
- Client communication and owner consent
• WITH SIGNATURES!
• Thorough history [including medications/supplements]
• Physical examination
• Dietary restriction [whenever possible]
• Laboratory data
• Determination of surgical risk [ASA status]
• Patient Stabilization
• Pre-surgical medications
What should be discussed with owners prior to surgery?
• Prior to surgery owner should be informed about:
• Diagnosis
• Prognosis
• Surgical options
• Non-surgical options
• Potential complications *
• Post-operative care
• Cost
What is important to include in your pre op patient history? Who is the history obtained from? What are the 2 types of histories?
• Regardless of the procedure, make sure you’re aware of previous medical history
• Usually obtained from the owner or caregiver
• In an emergency, a brief history is usually given [eventually a thorough history is obtained]
• General history vs. Specific history
• Should always include – signalment, diet, exercise, past medical problems/surgery, any
recent treatment
What is the reasons for pre operative exams? What should you be looking for?
• Determines if the patient is healthy enough to safely undergo anesthesia and surgery
• Systematic evaluation of all body systems
• Evaluation of pre-anesthetic physical status
• Patients general body condition should be noted
• Body condition, attitude, and mental status
• Ensure thorough cardiac evaluation and lung function assessment
• Rule out a heart murmur or abnormal arrythmia
• +/- Full neuro and ortho examination
• Remember to check kennel
• Looking for diarrhea or vomiting
What are the diet restrictions that can be in place for monogastric animals?
• NPO
• Withhold food for 6 – 12 hours prior to surgery [pending patient status]
• Continue to offer water
• Monogastric Animals [ie: dogs, cats, swine]
• Fast 6 – 12 hours prior
What are the diet restrictions that can be in place for ruminants ?
• Ruminants [ie: cattle, sheep, goats]
• Fast ~12 – 24 hours prior
What are the diet restrictions that can be in place for rodents/ Rabbits ?
• Rodents and Rabbits [includes mice, rats, guinea pigs, hamsters]
• High metabolic rate
• No fasting prior
What are the diet restrictions that can be in place for underage animals (< 8 weeks of age or < 1lb) ? Why?
• Underage Animals [<8 weeks of age; <1 lb]
• Hypoglycemia concerns
• Do not withhold water
• Withhold food 1 – 2 hours prior to anesthetic event
In diabetic patients when should you monitor their blood sugar? What should their insulin dose be if given prior to procedure. What are other considerations for diabetic patients?
In young patients, when should you monitor their blood sugar?What are other considerations for young patients? How long should they be fasted before the procedure?
When should antiemetic, antacid, and promotility medications be given to patients who are going into surgery?
Patients at risk for regurgitation, Emergent patients.
What is an important thing to remember about prepping emergent patients for surgery?
They must first be stabilized.
What is the benefits of pre surgical bloodwork? What things should we consider when doing/ choosing our presurgical bloodwork?
• Depends on the animal’s physical status and the procedure being performed
• Elective or routine procedure
• Emergency
• Reduces risk and increases safety
• Provides a baseline for the patient
• Takes into account patient’s behavior
• Normal bloodwork -> Proceed with surgery
• Abnormal bloodwork -> Workup and/or treat prior to anesthesia vs. emergency surgery
Small animal: What is the typical presurgical bloodwork for patients undergoing elective procedures ( ~ 6 months- 4 years)?
• Patients undergoing elective procedure [~6 months – 4 years]
• Hematocrit [PCV]
• Total Protein [TP]
• +/- Limited biochemical and urine screening [BUN, Creatinine, USG]
Small animal: What is the typical presurgical bloodwork for mature adults ( 5-7 years)?
• Mature adults [5 – 7 years]
• Complete blood count [CBC]
• Comprehensive serum biochemistry profile [Chemistry Panel]
• Urinalysis
Small animal: What is the typical presurgical bloodwork for 8 + years?
• 8+ years
• Complete blood count [CBC]
• Comprehensive serum biochemistry profile [Chemistry Panel]
• Urinalysis
• Thyroid Panel [minimum T4]
Small animal: What other additional testing should be ran prior to anesthesia/ surgery and what would be reasons to consider adding this testing on?
• Additional Testing
• Coagulation function test, especially for patients with liver disease, maldigestion disorders, NSAID usage,
and breed predisposition
Equine: What is bloodwork determined based on in horses?
• Indicated for horses based on age and systemic statu
Equine: What kind of bloodwork should be ran for a healthy horse under 4 years old?
• Horses younger than 4 years old and healthy
• Packed cell volume [PCV]
• Total Protein
Equine: What kind of bloodwork should be ran for an systemically ill horse greater than 4 years old?
• Horses greater than 4 years old and systemically ill
• Complete blood count [CBC]
• Chemistry Panel
What panel should be done for right sided abomasal disease of a dairy cow?
Electrolyte measurement for right-sided abomasal disease of the dairy cow
What test should be done on a dairy cow to rule out ketosis?
• Urinalysis in the dairy cow to evaluate the presence of ketosis
What other test should be ran if urinary problems are suspected in large animals?
• Measurement of BUN [blood urea nitrogen] and Creatinine, if urinary problems are suspected
What test is important to run in horses with colic prior to laparotomy?
Analysis of peritoneal fluid prior to laparotomy for horses with colic
What do you need to consider when stabilizing a patient? What may you need to do?
• Patients should be stabilized as thoroughly as possible before surgery
• Correct fluid deficits
• Stable dehydrated open pyometra patient
• Correct acid-base and electrolyte abnormalities
• Treat underlying infection
What is maropitant? What is the dose? When should it be given? What does it do?
Maropitant [Cerenia] – 1mg/kg 45 minutes – 1 hour before pre-medications
• Reduces vomiting, especially if using Hydromorphone
• May have anti-inflammatory properties
• Potential smoother recovery from gas anesthesia and hasten return to eating
What are the different premedication drugs?
• Pre-medication – Many different variations and combinations
• Dexmedetomidine/Butorphanol
• Midazolam
• Diazepam
• Hydromorphone
• Methadone
• Ketamine
What are preemptive analgesia drugs?
• Pre-emptive analgesia
• NSAID [Carprofen, Meloxicam]
• Local Anesthetic [Lidocaine, Bupivacaine]
• Opioids
What is a common antibiotic used in surgical patients?
+/- Antibiotics [ie: Cefazolin]
What should you do in terms of preparing patient for surgery via eliminations?
• Allow patient to urinate and defecate prior to induction
• Abdominal Surgery
• Empty bladder
• Colonic Surgery
• +/- Enema
• Bladder Distention
• Could lead to a rough recovery
What are reasons to delay surgery?
• High Fever
• Rule out stress
• Recent Gastrointestinal Signs [24 – 48 hours]
• Pyoderma
• Infection
• Urinary Tract Infection [URI]
• CIRDC
• Sick
• Uncontrolled Diabetic
• Uncontrolled Hyperthyroid
• In heat
What are halsteds surgical principles?
- Strict asepsis
• Hemostasis
• Preservation of blood supply [accurate anatomical dissection]
• Gentle tissue handling and manipulation
• Avoid excess tension on tissue during wound closure
• Accurate tissue apposition in wound closure
• Elimination of dead space
What are the tips to reduce surgical site infections not related to the surgery itself?
What are the tips to reduce surgical site infections during the surgery?
What are the 4 surgery/ wound classifications?
• Clean
• Clean-Contaminated
• Contaminated
• Dirty
What is a clean wound/ surgery? What are examples?
• Involving non-contaminated, non-traumatic, and non-inflamed surgical site
• Gastrointestinal, urinary, and respiratory tract not entered
• Examples:
• Neuter/Ovariohysterectomy
• Arthrotomy for removal of a chip fracture of a carpal bone
• Elective orthopedic surgery
• Total hip replacement • PDA
What is a clean- contaminated wound/ surgery? What are examples?
• Operative wounds/surgery in which the gastrointestinal, urinary, and respiratory tract
is entered, under controlled conditions without unusual contamination
• Examples:
• Abomasopexy [displaced abomasum in dairy cows]
• Enterotomy [foreign body removal]
• Small Intestinal Resection
• Bronchoscopy
What is a contaminated wound/ surgery? What are examples?
• Surgery where gastrointestinal contents or infected urine spill into an open cavity
• Examples:
• Cystotomy with spillage of infected urine
• Bile spillage during a Cholecystectomy
• Surgery where major break in aseptic technique occurred
• Open, fresh, accidental wounds
• Lacerations
What is a dirty wound/ surgery? What are examples?
• Old traumatic wounds with purulent discharge
• Devitalized tissue
• Surgery where a hallow organ is perforated or fecal contamination occurs
• Gross spillage of contaminated body contents
• Examples:
• Septic peritonitis
• Rupture/perforated intestines, gallbladder, or pyometra
• Abscess
What are surgical site infections? What can you see at the site?
• Infection that occurs in the skin +/- subcutaneous tissue at a surgical site within 30
days of the surgical procedure
• Inflamed wound or incision site with discharge
What are the typical bacteria that causes surgical site infections?
• Endogenous microbial flora are common culprits
• Staphylococcus aureus
• Streptococci spp.
How do you clip hair for a surgical site? Where should this occur? What blade is used? How do you properly clip the hair? What should you avoid/ what other surgical prep should be done at this time?
• Should take place in the preparation room
• Anesthesia/surgical prep area
• Performed under anesthesia
• Clip hair and vacuum over propose surgical field
• Initial clipping should be done with the hair growth pattern
• Subsequent clipping should be against the pattern of hair growth to obtain a closer clip
• Use a number 40 blade
• Avoid razor burn
• Express bladder
Disinfectants/ antiseptics
How do you appropriately prepare the skin? Where should this be done? How long must the scrub stay on to be effective? Which are the most common/ What are the different kinds used for?
- Aseptic surgical site prep [location = OR]
- Select appropriate antiseptic solution
- Chlorhexidine 4% scrub – most commonly used
- Povidone-iodine 10% scrub – periocular and some orthopedic procedures
- Alcohol based antiseptic – follow manufacturer’s instructions
- Aseptic preparation based on contact time with antiseptic
- Minimum 5-minute contact time!
- Exception when using alcohol-based antiseptics
- Remember – 15 minutes for PVI when using it as a sporicidal
How many rounds of scrubs are usually done? Where does this take place again?
• Takes place in the OR
• If skin is very dirty – perform an initial scrub
• 3 additional scrubs performed
• Common combination is chlorhexidine and alternating with alcohol
• Scrub at incision site, near center, and move outwards in a circular fashion
What are the goals of skin preparation?
• Reduce resident skin flora to prevent infection
• Achieve residual antiseptic activity
• It is NOT possible to completely sterilize the skin
What is important for patient positioning?
• Vital for effective surgical procedure
• Positioning dependent on the procedure
• Prep area
• Heat source
• +/- trough
What are the three typical positions patients are placed in for surgery?
• Dorsal recumbency
• Sternal recumbency
• Lateral recumbency
Why do we give patients fluids intraoperatively? What is the typical areas that cause increased fluid losses? What should we consider for fluids in surgery? What is the typical rate of fluids?
• Intraoperative fluid therapy helps restore and maintain tissue fluid, as well as electrolyte homeostasis and central euvolemia
• 10 – 15 mL/kg/hour of crystalloid fluids
• Lower rate (5 mL/kg/hour) may be used for healthy patients undergoing less invasive elective procedures
• Fluid losses
• Large abdominal and thoracic incisions have much larger evaporative losses
• Prewarming fluids
What is the purpose of draping? When does draping occur? Who should be draping? What are the draping options?
• Creates and maintains a sterile field around operative site
• Occurs after patient has been positioned on OR table and skin has been prepped
• Performed by a gowned and gloved surgical team member
• Draping options:
• 4 corner drape
• Pre-made fenestrated drape
• Making fenestrated drape
What are the draping techniques used during orthopedic limb procedures?
• Orthopedic procedures on limbs
• Free-draping technique
• Limb is suspended using IV stand with foot enclosed in a clean latex glove
• Vet w2rap is used and glove is secured to the foot with adhesive tape • Triangle of drapes are placed around base of limb
For a minor procedure, what kind of drape should be used? A spay and neuter? Tail amputation?
• Minor procedures [ie: lumpectomy[
• Small fenestrated drape is sufficient
• Spay and neuter
• Small fenestrated drape if sufficient
• Tail amputation
What does preoperative monitoring allow for?
• Adequate anesthesia
• Adequate analgesia
• Adequate immobilization
• Early notice of trends, which may develop into life threatening conditions
When are perioperative antibiotics recommended? When would a clean surgery require antibiotic therapy?
• Perioperative antibiotics are recommended in patients receiving an implantable
device, undergoing prolonged ( 90 minutes) surgery, or undergoing a contaminated
procedure
• “Clean Surgery” does not require on-going antibiotic therapy unless there is a break in
sterile technique
True or False: If surgical sites are properly prepped, patients with healthy immune systems should be able to resist infection by most surface contaminants
True
When does the risk of infection increase in patients that are given perioperative antibiotics?
• For patients, the risk of infection is increased when antibiotics are given
incorrectly
• Example: At the wrong time or using the wrong dose
When should perioperative antibiotics be given? How often should they be repeated? When should prophylactic antibiotics for a procedure be discontinued?
If perioperative antibiotics are given, it should be administered within 1 hour before
the first incisions
• Ensure peak blood and tissue concentrations are reached before the incision is made
• Re-administered antibiotics every 90 – 120 minutes during anesthesia
• Based on the half-life of the antibiotic chosen
• Prophylactic antibiotics should be discontinued within 24 hours after surgery
What is the gold standard for antibiotic selection?
Getting a cytology
What are examples of times when antibiotics should be used?
• General Procedures:
• Treatment of severely contaminated or traumatized wounds
• Implants [ie: Mesh, bone plate, pacemaker]
• Respiratory Procedures:
• Resection of infected lung
• Gastrointestinal Procedures:
• Enterotomy with necrotic segment
• Pancreatic abscess
What are the types of surgical site closure? What is the importance of surgical site closure (aside from the obvious intestines hanging out)? When do you typically remove the closure? What should you do before removal?
• Suture vs. Staples
• Keeps the skin margins closed
• Good skin apposition
• Evaluate incision healing prior to removal
• Normal removal time is 10 – 14 days later
How can you maintain sterility before and during surgery?
• Proper gowning and gloving
• Surgery team member should face the sterile field
• Back of gown is not considered sterile
• Do not touch or lean over a non-sterile area
• Arms and hands should remain above waist level and below shoulder level
• Arms should not be folded
• Clasp in front of body [above waist]
• Sleeves should be considered sterile from 2 inches above the elbow to the stockinette cuff
What are the benefits of appropriate post operative care?
• Aid healing
• Minimizes risk of additional corrective surgeries
• Speeds recovery
• Vital to a successful surgery outcome
What are the things that should be done for immediate post operative care? What are their benefits/ how do they help our patients?
• Move patient to a warm, dry area and monitor vital signs every 15 minutes until patient is sternal
• Keep patient is sternal recumbency during recovery
• Turn side to side frequently to prevent pooling of fluid in recumbent side
• Remove endotracheal tube when swallowing/chewing
• Prevents regurgitation and vomiting
• Do not return to kennel until able to maintain body temperature and hold itself in sternal position
What should be done daily by the veterinarian if their post op patient remains in hospital?
• Full physical examination and evaluation of parameters [daily]
• Appearance
• Attitude
• Appetite
• Hydration Status
• TPR
• Signs of Pain
• Surgical Incision Monitoring
• Look for clinical signs of infection, seroma, hematoma, suture break down, and wound
dehiscence
• Allows you to adjust treatment plan if needed
What should be done daily by the LVT in regards to post op patient care?
• LVT’s will be your second pair of eyes when you are not with the patient
• Hospitalization treatment sheet
• Vitals
• Fluids
• Treatments
• Diet
• Lab Data
• Make sure the sheet is signed and filled out correctly
What is considered a delayed recovery?
Delayed recovery
• >30 minutes since termination of anesthesia
What is considered a stormy recovery?
• Where many complications can occur
• Delayed recovery
• >30 minutes since termination of anesthesia
• Rapid and complicated recovery
• Dysphoria
• Pain
• Emergency delirium
• Bladder distension
• Fear, Anxiety, Stress [FAS]
What are signs of a rapid/ complicated recovery?
• Rapid and complicated recovery
• Dysphoria
• Pain
• Emergency delirium
• Bladder distension
• Fear, Anxiety, Stress [FAS]
What is dysphoria? What drugs can cause this? What drugs can be given to help counteract this? What can be clinically seen in patients?
• State of unease due to agitation and anxiety
• Seen with pure mu opioids
• Morphine, Hydromorphone, Fentanyl, Methadone
• Vocalization, panting, difficulty settling down, or restlessness
• Naloxone – carefully titrated
• Multiple doses may be needed since it has a short duration or action
• Butorphanol can also be given to help calm patient.
What is pain? What can indicate pain in our patients? What are considerations we must make to help relieve pain? What is needed if a patient has a high pain score?
• Unpleasant sensory and emotional experience that is associated with actual or
potential tissue damage
• Observe posture and facial expressions
• Determine whether your patient is painful vs. dysphoric
• When was last analgesic dose and what is the drugs duration of action?
• Does the patient need additional analgesia?
• Determine how painful procedure was
• Gently palpated affected surgical area
• Analgesic are needed with a high pain score
• Opioids [Morphine, Fentanyl, Hydromorphone, Methadone]
• NSAIDs [Carprofen, Meloxicam, Onsior]
What is emergency delirium? How can you help stop patients from thrashing and prevent injury?
• State of mental confusion and psychomotor agitation marked by:
• Hyperexcitability, restless, thrashing, and vocalization
• Occurs in the immediate recovery paid [right after inhalant anesthesia is
discontinued]
• Patients do not interact with humans and are unaware of environment
• Thrash uncontrollably and require immediate intervention to prevent injury
• Propofol
• 0.5-1mg/kg IV [SLOW}
What is FAS? What can be done to help mitigate this in patients?
• Fear, Anxiety, and Stress
• Perform assessment of the patient’s temperament prior to anesthesia and determine
if extra sedation is needed
• Trazodone
• 5-10mg/kg PO ~30-60 minutes prior to high anxiety event • Gabapentin
• 20mg/kg PO ~30-60 minutes prior to high anxiety event • Low-dose acepromazine
• 0.01mg/kg IV – cats and dog • Low-dose dexmedetomidine
• 0.001mg/kg IV – cats and dogs
What is important post op care at home?
• Notation of any Bruising, seepage, odors at incision site
• Normal vs. signs of infection?
• Medications
• Pain meds [~3-14 days]
• Antibiotics [~5-7 days]
• Avoid antibiotic resistance
• Activity Restriction
• Appetite
• Elimination
• Bathing
• Cones/E-collars
• Bandages, splints, cast, drain care
• DO NOT send home with IVC or bandage
over IVC site
What should be in patients discharge instructions?
• Hospital and contact information
• Patient information
• Anesthesia side effects
• Food and water instructions
• Medication instructions
• Home care instructions
• Complications
• Recheck
