Perioperative Evaluation, Patient Prep, and Post-Operative Care Flashcards
What is pre-operative assessment considered? What 3 things does it provide?
pre-surgical planning
- solid foundation for surgical procedure
- baseline physiologic data for patient
- facilities assessment of disease and relevance to surgery
What 8 things make up the pre-operative evaluation of the patient?
- client communication and owner consent (with signatures!)
- thorough history, including medications and supplements
- physical exam
- dietary restrictions
- lab data
- determination of surgical risk (ASA status)
- patient stabilization
- pre-surgical medications
What 8 things should owners be informed about prior to surgery?
- diagnosis
- prognosis
- surgical options
- non-surgical options
- potential complications***
- post-operative care
- authorization to surgery and acceptable of risks
- estimates (low to high)
Who should the patient history be received from?
owner/caregiver - someone that spends the most time with the patient
- should be in-depth and include previous medical history
How does the history change in an emergency situation?
can be more general and brief and a thorough history can be obtained later
What is generally included in a good history?
- signalment (species, breed, age, gender, reproductive status)
- diet
- exercise
- past medical problems or surgeries
- recent treatment
What is the point of a pre-operative exam? What 5 things does it include?
determines if the patient is healthy enough to safely undergo anesthesia and surgery
- systemic evaluation of all body systems
- evaluation of pre-anesthetic physical status
- body condition (body, attitude, mental status)
- thorough cardiac evaluation and lung function assessment (no murmur/arrythmia)
5 (+/-) full neuro and ortho exam
What should happen if there are concerning or odd findings on the pre-operative exam?
work up before surgery and possibly hold off on it
What dietary restriction is observed for animals before surgery? What does it look like in monogastric animals, ruminants and rodents/rabbits?
NPO - withhold food, offer water
MONOGASTRIC ANIMALS: fast 6-12 hrs prior
RUMINANTS: fast 12-24 hrs prior
RODENTS/RABBITS: high metabolic rate, no fasting necessary
What are the major concerns for fasting in underage animals before surgery?
hypoglycemia can lead to seizures, so only withhold food 1-2 hrs prior to anesthesia
(no withholding water!)
When is water typically withheld before surgery?
when vomiting and regurgitation is a concern
How does the need for pre-operative bloodwork change depending on the situation? What are 2 reasons for doing it?
depends on the animal’s physical status and the procedure
- elective/routine procedure = do it
- emergency = go right into surgery
- reduces risk and increases safety
- provides a baseline for the patient
(take into account for the patient’s behavior)
What bloodwork should be done for patients 6 months to 4 years old undergoing elective procedures? Mature adults? 8+ years old?
6 MONTHS - 4 YEARS: hematocrit [PCV], total protein [TP], limited biochemical and urine screening [BUN, creatinine, USG]
5-7 YEARS: complete blood count [CBC], comprehensive serum biochemistry profile [chemistry panel], urinalysis
8+ YEARS: CBC, chemistry panel, urinalysis, thyroid panel [minimum T4]
(older = more tests done)
What bloodwork should be done in horses younger than 4 years old and healthy? Horses greater than 4 years old and systemically ill?
packed cell volume (PCV), total protein
complete blood count (CBC), chemistry panel
(older = more in-depth tests)
What is the point of electrolyte measuring and urinalysis in dairy cows before surgery? What should be measured if urinary problems are suspected?
right-sided abomasal disease
evaluate the presence of ketosis
BUN and creatinine
What should be analyzed in horses with colic before they undergo laparotomy?
analysis of peritoneal fluid
What is the purpose of the ASA Physical Status of a patient?
classify a patient to know the likelihood of a cardiac event and serves as a guideline for determining surgical risk and prognosis
In what 3 ways are patients stabilized before surgery?
- correct fluid deficits
- correct acid-base and electrolyte abnormalities
- treat underlying infection
(all in elective procedures, not necessarily emergencies)
What are 3 major benefits of giving patients Maropitant (cerenia) before surgery? When is it given?
- reduces vomiting, especially when using Hydromorphone
- may have anti-inflammatory properties
- has the potential to cause smoother recovery from gas anesthesia and hasten return to eating
1 hr before pre-meds
What are 6 common pre-medications given before surgery?
- Dexmedetomidine/Butorphanol
- Midazolam
- Diazepam
- Hydromorphone
- Methadone
- Ketamine
What are 3 common pre-emptive analgesias given to patients recovering from surgery? What additional medications are often included?
- NSAIDs - Carprofen, Meloxicam
- local anesthetics - Lidocaine, Bupivacaine
- opioids
antibiotics - Cefazolin
Why are patients allowed to urinate and defecate prior to induction?
makes surgery easier - less getting in the way, bladder distension can lead to a rough recovery
abdominal surgery —> empty bladder
colonic surgery —> enema
In what 6 situations should surgery be delayed?
- high fever - rule out stress!
- recent gastrointestinal signs (24-48 hrs) - will only get worse after surgery
- pyoderma (skin infection)
- infection - UTI, CIRDC (kennel cough)
- sick - uncontrolled diabetic or hyperthyroidism
- in heat - increases chances of complications, tissues are swollen and more friable
What are Halsted’s 7 surgical principles?
- strict asepsis
- hemostasis (control bleeding and hemorrhage)
- preservation of blood supply (accurate anatomical dissection)
- gentle tissue handling and manipulation
- avoid excess tension on tissue during wound closure
- accurate tissue apposition in would closure (no overlap!)
- elimination of dead space
What are 6 non-surgical ways to avoid surgical site infections (SSI)?
- treat existing infections
- minimize hospitalization time
- pre- and post-op treatment
- proper patient prep
- clipping and prepping skin
- minimize number of OR personnel
What are 6 surgical ways to avoid surgical site infections (SSI)?
- atraumatic surgical technique
- debride thoroughly
- minimize dead space and suture tension
- use good hemostasis
- accurate skin closure
- minimize surgery time and sutures
What are the 4 wound/surgery classifications?
- CLEAN - non-contaminated, non-traumatic, non-inflamed surgical site, where the GI, urinary, and respiratory tracts are not entered
- CLEAN-CONTAMINATED - operative wounds/surgery where the GI, urinary, and respiratory tracts are entered under controlled conditions without unusual contamination
- CONTAMINATED - GI contents or infected urine spills into open cavity
- DIRTY - old, traumatic wounds with purulent discharge, including devitalized (not healthy tissue), hollow organ perforation, and fecal contamination (gross spillage of contaminated body contents
Give examples of each wound/surgery classification.
- CLEAN - neuter/ovariohysterectomy, arthrotomy for removal of chip fracture or carpal bone, elective orthopedic surgery (total hip replacement), patent ductus arteriosus correction
- CLEAN-CONTAMINATED - abomasopexy, enterotomy (not all the time), small intestial resection, bronchoscopy
- CONTAMINATED - cystotomy with spillage of infected urine, bile spillage during cholecystectomy, major break of aseptic technique, open/fresh/accidental wounds, lacerations
- DIRTY - septic peritonitis, rupture/perforated intestines, gallbladder, or pyometra, abscess
What are surgery site infections? What are 2 common culprits? How does it manifest?
- infection that occurs in the skin +/- subcutaneous tissue at a surgery site within 30 days of the surgical procedure
Staph. aureus and Streptococci spp. that are endogenous microbial flora
inflamed wound or incision site with abnormal discharge
Where should the animal be clipped for surgery? How does the clipping occur? What blade is used?
in a preparation room (anesthesia/surgical prep room) while the animal is anesthetized (NOT IN OR!)
- initial clipping done with the hair growth pattern
- subsequent clipping done against the patter of hair growth for a closer clip
40 blade —> avoid razor burn!
When/where is the bladder expressed?
before surgery while being prepped in a preparation room
Where is the surgical site aseptically prepped? What are the 3 common antiseptic solutions used and their concentrations?
OR
- chlorohexidine 4% scrub - most common
- povidone-iodine 10% scrub - periocular and orthopedic
- alcohol-based antiseptics - follow manufacturer’s instructions
What is aseptic preparation based on?
contact time with antiseptic (minimum 5 minute contact time!)
What aseptic solution does not have a minimal contact time?
alcohol-based aseptics
How much contact time is necessary fo PVI when it is used as a sporocidal?
15 minutes
What scrubs take place during skin prep?
- initial scrub if patient is dirty
- 3 scrubs of alternating chlorohexidine and alcohol scrubs
What technique is used to scrub skin before surgery?
scrub at incision site, near the center, and move outwards in a circular fashion
What is the point of draping a patient? When does this occur? How is it performed?
creates and maintains a sterile field around operative site
after the patient has been positioned on the OR table and skin is prepped
performed by a gowned and gloved surgical team member
What are the 3 draping options?
- 4 corner drape
- pre-made fenestrated drape
- making a fenestrated drape
How are orthopedic procedures on limbs draped?
- free-draping technique where the limb is suspended using an IV stand with the foot enclosed in a clean latex glove covered by vet wrap for security
- triangle of drapes placed around the base of the limb
When are small fenestrated drapes appropriate?
- minor procedures (lumpectomy)
- spay
- neuter
- tail amputation
What 4 things does pre-operative monitoring allow?
- adequate anesthesia
- adequate analgesia
- adequate immobilization
- early notice of trends that may develop into life-threatening conditions
In what 3 conditions are perioperative antibiotics recommended? Why shouldn’t most patients need perioperative antibiotics?
- patients receiving implantable devices
- prolonged procedures (more than 90 mins)
- contaminated procedure
surgical sites should be properly prepped and the immune system should be able to resist infection by most surface contaminants
“Clean surgery” does not require on-going antibiotic therapy. What is an exception?
if there is a break in sterile technique
When is the risk of infection increased in a patient?
when antibiotics are given incorrectly (wrong time or dose)
(resistance!)
When should perioperative antibiotics be administered? Why? How are they given throughout the surgery?
1 hr before the first incision to ensure peak blood and tissue concentrations are reached before the incision is made
readministered every 90-120 mins during anesthesia based on the half-life of the antibiotic chosen
When should prophylactic antibiotics be discontinued?
within 24 hours after surgery
What is the gold standard for antibiotic selection?
obtaining cytology
Which general, respiratory, and GI procedures should use perioperative antibiotics?
GENERAL: treatment of severely contaminated or traumatized wounds, implants (mesh, bone plate, pacemaker)
RESPIRATORY: resection of infected lung
GI: enterotomy with necrotic segment, pancreatic abscess
What is the point of using sutures and staples to close surgery sites? When should they be removed?
keep skins margins closed for skin apposition
10-14 days after surgery once the incision healing has been evaluated
Why should the surgery team face the sterile field? What portion of gown sleeves is considered sterile?
back of the gown is not considered sterile
2 inches above elbow to stockinette cuff
Why is post-operative care so important?
- aids healing
- minimizes risk of additional corrective surgeries
- speeds recovery
- vital to successful surgery outcome
How is the patient recovered from anesthesia?
patient is moved to a warm, dry area and vital signs are measured every 15 mins until they are sternal
Why is the patient moved side to side during anesthesia recovery? When is the endotracheal tube removed? Why?
prevents pooling of fluid on recumbent side
when the gag reflex returns and the patient begins swallowing/chewing - prevents regurgitation and vomiting
When is the patient returned to their kennel?
when anesthetic recovery is complete - body temperature is maintained and patient can hold themselves in a sternal position
What is the DVM responsible for during post-op care? Why?
full physical examination and daily evaluation of parameters
- appearance, attitude, appetite, hydration, TPR, pain, surgical incision monitoring (look for infection, seroma, hematoma, suture breakdown, wound dehiscence)
allows for an adjustment to treatment plan if needed
What is the LVT responsible for during post-op care?
“second pair of eyes” when DVM is not with patient; fills out hospitalization treatment sheet (vitals, fluids, treatments, diet, lab data)
What is a stormy recovery? What 2 things does it cause?
patient is not recovering correctly, which can cause many complications
- delayed recovery > 30 mins since termination of anesthesia (anesthesia remained in system, can lead to hypothermia)
- rapid and complicated recovery - dysphoria, pain, emergency delirium, bladder distension, fear/anxiety/stress (FAS)
What is dysphoria? What are the clinical signs? What drugs is this most common in? How can it be reversed?
state of unease due to agitation and anxiety
- vocalization, panting, difficulty settling down, restlessness
mu opioids - Morphine, Hydromorphone, Fentanyl, Methadone
- carefully titrated Naloxone (short duration/action = multiple doses)
- Butorphanol
What does pain after surgery (with analgesia) suggest? How can it be seen? What additional analgesia can be given?
unpleasant sensory and emotional experience associated with actual or potential tissue damage
posture or facial expressions
(with high pain score)
- opioids: Morphine, Fentanyl, Hydromorphone, Methadone
- NSAIDs: Carprofen, Meloxicam, Onsior
What 3 things need to be determined before treating a painful patient after surgery?
- pain vs dysphoria
- When was the last analgesic dose and what is the drug’s duration of action? More analgesia needed?
- How painful was the procedure? gently palpate affected surgical area
What is emergency delirium? When does it most commonly occur? How can this be seen?
state of mental confusion and psychomotor agitation
immediate recovery right after inhalant anesthesia is discontinued
- hyperexcitability, restlessness, thrashing (propofol to avoid injury)
- vocalization
- patient doesn’t interact with humans and are unaware of the environment
How should fear, anxiety, and stress be treated?
perform assessment of the patient’s temperament prior to anesthesia to determine if extra sedation is needed
- Trazadone
- Gabapentin
- low-dose acepromazine
- low-dose dexmedetomidine
How is post-operative care done at home?
- medications (pain meds for 3-14 days and antibiotics for 5-7 days)
- activity restriction
- appetite monitoring
- elimination may be held for a day or so
- no bathing
- cones/e-collars
- bandages, splints, cast, drain care
- DON’T send home with IVC or bandage over IVC site
What 6 things should be included in discharge instructions?
- hospital contact information
- patient information
- anesthesia side effects
- food and water instructions
- medication instructions
- home care instructions
