Surgical Nursing Flashcards
list benefits of performing a neurological exam
breaks down complex presentations
identify if neurological or other condition
localisation of condition
aid diagnosis and prognosis
continual assessment of patient condition
state aims of neuro exam
determine if condition is neurological
determine where the condition is
determine potential causes
what is the purpose of localisation of neuro conditions?
aids differential diagnoses
where can neurological conditions be localised to?
brain - forebrain, cerebellum, brain stem
spinal cord - C1-C5, C6-T2, T3-L3, L4-S2
peripheral nerves
neuromuscular
what is the 5 finger rule of localisation (neuro)?
signalment
onset - acute vs chronic
progression
symmetry
pain
what are the different parts to a neuro exam?
hands off observation
hands on exam
what is examined in hands off observation in neuro exam?
mentation
gait
posture
what is examined in hands on observation in neuro exam?
postural reactions
spinal reflexes
cranial nerves
sensory evaluation
palpation
what should be considered when assessing mentation?
state - alert, obtunded, stuporous or coma
are reactions to environment as normally expected for this patient
what should be considered when assessing gait in a neuro exam?
common presentation, not always neurological
can they generate coordinated movements and walk normally
breed differences
head turn or tilt, ventroflexion, curving of the spine
decerebrate rigidity or decerebellate rigidity
stance
how is a gait exam performed?
owner walks animal up and down at varying speeds as needed
can use sling or support if needed
what is decerebrate rigidity?
extension of all limbs, head and neck
non-ambulatory in lateral
what is decerebellate rigidity?
extension of thoracic limbs, head and neck
hind limbs flexed or flacid
what is the purpose of testing postural reactions?
test sensory nerves in ascending tract in spinal cord, brainstem and forebrain, descending tracts in brainstem and spinal cord, motor neurones and muscles
why cant postural reaction tests localise neuro lesions?
tests are affected by lesions in any area
list types of postural reaction tests
proprioception - replacing feet
hopping - lift each leg in turn and move from side to side
visual placing - should place feet when moved to table
tactile placing - same as visual but eyes covered
hemi-walking and wheelbarrowing
what does spinal reflexes test assess?
all limbs function
how are thoracic limbs tested in spinal reflexes?
withdrawal
extensor carpi radialis and biceps brachii reflexes
how are pelvic limbs tested in spinal reflexes?
withdrawal
patella and cranial tibial and gastrocnemius reflexes
list types of spinal reflex tests
thoracic limbs
pelvic limbs
perianal reflex
panniculus reflex
cutaneous trunchi reflex
how are withdrawal reflexes tested?
non-painful pinching of the toe inducing a reflex
how is a patella reflex test performed?
knocking patella hammer to cause kicking
how is perineal reflex tested?
pinching around perineum to cause contraction
how is paniculus reflex performed?
pinching thoracic skin causing flinching of the skin
how is cutaneous trunci reflex performed?
pinching along each side of the spine to observe skin twitches
what is the purpose of cutaneous trunci reflex test?
tests segmental nerve to aid localisation
list tests for cranial nerves
menace response
gag reflex
PLR
oculocephalic reflex
nystagmus
palpebral reflex
describe the menace response
reaction when hand moved to the face
describe the oculocephalic reflex
observing eye tracking when moving the head
how do you assess sensory function in neuro exams?
panniculus reflex
deep pain perception
where are deep pain tracts found and what is the impact of this?
in the spinal column
only affected by severe spinal damage
how do you assess deep pain?
pinching digits to induce pain, should see reaction not just reflex
why do you palpate to assess neuro function?
detect any abnormalities
why is pupillary assessment important in neuro patients?
can be miotic, mydriatic or anisocoria
rapid deterioration indicated when pupil goes from miotic to mydriatic, intense monitoring and treatment needed
midsized fixed pupils indicate very poor prognosis, brain herniation or brain death
monitor for any changes
define miotic pupils
constricted
define mydriatic pupils
dilated
define anisocoria
asymmetric pupils
which motor neurones can be effected by brain or spinal cord lesions?
upper and lower motor neurones
where are UMNs located?
between cerebral cortex and spinal cord
what do UMNs do?
send signals to LMNs
what is the effect of UMNs being damaged?
stronger reflexes than normal
increased muscle tone with chronic muscle atrophy
where are LMNs located?
connect CNS to effector organ
what do LMNs do?
cause effector organs to contract
what is the effect of LMNs being damaged?
weak or absent reflexes
reduced muscle tone and rapid muscle atrophy
flacid paresis and paralysis
what is the purpose of grading spinal cord injuries?
allows objective assessment
ongoing monitoring
aids prognosis
what is seen in grade 1 spinal injuries?
pain
no neurological deficits
normally walking
what is seen in grade 2 spinal injuries?
ambulatory paraparesis
walking with neurological defecits
weakness or incoordination of pelvic limbs
what is seen in grade 3 spinal injuries?
non-ambulatory paraparesis
unable to walk without assistance but good pelvic limb movement
what is seen in grade 4 spinal injuries?
paraplegia with intact nociception
no voluntary movement in pelvic limbs
can feel toes
deep pain positive
what is seen in grade 5 spinal injuries?
paraplegia without nociception
no voluntary movement in pelvic limbs
deep pain negative
what assessments should be done for nursing neuro patients?
consider previous and current conditions
normal activities to make care as normal as possible
owner desires and expectations
owners ability to care
what are patient considerations for neuro patients?
ambulation
surgery
continence
temperament
recumbency
normal routine
what are common nursing considerations for neuro patients?
decreased motor activity
bladder and bowel management
pressure sores
wound management
pain management
respiratory support in severe cases, may get aspiration pneumonia
state the purposes of physiotherapy
improve local and body circulation
reduce pain
bond with patient
prevent pressure sores
aid motor recovery
improve joint health
limit muscle wastage
prevent contracture
what are the goals of physiotherapy?
relearn motor movements
stimulate proprioceptive relearning and gait
when should you start physio?
as early as possible and increase intensity
list types of physiotherapy
massage
PROM
assisted exercise
active exercise
proprioceptive exercise
neuromuscular e-stim
hot/cold therapy
hydrotherapy
laser therapy
how is massage performed?
light pressure applied to patients limbs in strokes and circular movement
move towards heart if oedema
what are the benefits of massage?
calms patient
prepares for handling
aid circulation
mobilised dermal and subdermal tissue
warms muscle
how is PROM performed?
flex and extend joints through normal range of motion
what are the benefits of PROM?
improve joint health without active contraction
aid gait patterning
what are examples of assisted exercises?
standing
walking
sit to stand
stand to sit
3 legged standing
weight shifting
list examples of active exercise?
walking in different patterns
un assisted sit to stand
hydrotherapy
list examples of proprioceptive exercises
standing
wobble board
uneven surfaces
over poles
weaving
what are the benefits of neuro patients having physio on different surfaces?
aids sensory relearning
what are benefits of hot/cold therapy?
muscle relaxation
analgesia
what are the benefits of neuromuscular e-stim?
increased tissue perfusion
minimise muscle atrophy
how does e-stim work?
causes muscle contraction in patients who cant actively contract their muscles
what are considerations for physiotherapy on neuro patients?
previous injuries and surgery
patient temperament
client expectations and limits
disease processes
neurolocalisation
what is a common condition post-op in neurological patients?
urinary incontinence
list potential bladder issues
UTI
bladder atony - weakening bladder muscles
pyelonephritis
what makes UTI common in neuro patients?
urine is static in bladder as patient cant urinate continently
what can be a consequence of bladder distension?
pain
describe UMN bladder
distended
hard to express
describe LMN bladder
distended
easy to express
why does overflow incontinence happen?
patient is unaware bladder is full so urine leaks out
what are consequences of overflow incontinence?
urine scalding
risk of UTI
how do you manage neuro patients bladders?
manual expression 3-4x daily
intermittent catheterisation 2x daily
indwelling catheter
drug therapy to relax bladder to aid expression
why are neuro patients normally able to defecate without issues?
passing faeces is initiated by rectal wall stretching
what is a consideration for neuro patients who are continent?
may not be able to move away from excretions
what injury can make defecation reflex overactive?
UMN injury
how do you manage neuro patients bowel movements?
keep clean
check regularly
give opportunities to go on normal environment
why do pressure sores occur commonly in neuro patients?
likely recumbent
compression of local circulation causing ischemic necrosis
what is the progression of pressure sores?
mild erythema to full thickness ulcers and open wounds
how do you prevent pressure sores?
thick bedding
turn every 2-4 hours
donut bandages
porous bedding
inco pads
prop up with pillows
physio
close monitoring
keep skin dry
rapidly aggressively treat if start to form
how can you protect feet of neuro patients?
bandages or foot covers
how do you treat pressure sores?
keep clean and dry
debride if needed
antibiotics if needed
bandaging
how do you manage neuro patients surgical wounds?
cold therapy
analgesia
primapore initially
prevent patient interference
no neck leads for ventral slot
why do ventral slots have less issues than hemilaminectomy?
go through less tissue and muscle
less skin movement in recovery so hemi more prone to seromas
when can neuro patients self mutilate?
deep pain negative
paraesthesia
boredom
stress
define paraesthesia
feeling sensations that arent there
where does neuro surgery pain come from?
IVD
facets
nerve roots
muscles
meninges
tissue damage and compression causes pain
what are the benefits of preventing acute pain?
stop chronic pain
why is respiratory management important in neuro patients?
prone to hypoventilation
atelectasis due to recumbency
pneumonia
especially important in C spine patients
how does aspiration pneumonia occur and what are the consequences?
inhalation of GI contents causing pulmonary damage and inflammation
predisposes to bacterial infection
list signs of aspiration pneumonia
coughing
tachypnoea
harsh lung signs
crackles on auscultation
how do you care for aspiration pneumonia patients?
close monitoring
antibiotics
IVFT
oxygen
respiratory physio
may need ventilation
feed from height
regular turning
what are types of respiratory physiotherapy?
nebulisation - 10-15 minutes, in sternal if possible, breaks up secretions
vibration - shake patients chest walls on expiration for loosen aspirates
coupage - 10 minutes, loosens and allows patient to cough up secretions
define atelectasis
collapsed or underinflated lung
define borborygmi
stomach noises
define hyperpnoea
increased effort breathing
define ipsilateral
the same side
define modified transudate
fluid formed by leakage from normal/non-inflamed vessels
define orthopnoea
adaptation in posture to aid breathing
define TFAST
thoracic focused assessment with sonography for trauma patients
what should you consider when triaging thoracic patients?
signalment
onset
progression
what are signalment indications for different potential diagnoses for thoracic patients?
age - neoplasia more common if older, FeLV+ cats exception
species - mediastinal masses in cats
breed - tracheal collapse in yorkie, lung lobe torsion in pugs, chylothorax in afghans, FB in springer
lifestyle - indoor or outdoor cat, urban vas rural, fighting cats, gundogs
which speed of onset is more concerning in thoracic patients?
acute
list clinical signs commonly seen in thoracic surgical patients
tachypnoea
abnormal breathing - orthopnoea, hyperpnoea, dyspnoea, abdominal breathing
cough
pale mm
cyanosis
exercise intolerance
collapse
injuires
systemic illness
what is initial management of thoracic surgery patients?
minimise deterioration
monitoring
diagnostics
how can you minimise deterioration of thoracic surgery patients when first presenting?
oxygen
manage wounds if trauma and protect from further damage
what are you monitoring initially in thoracic surgery patients?
temperament
progression or deterioration
what diagnostics need to be done for thoracic surgery patients?
bloods
thoracocentesis for cytology and culture
imaging
tfast
why should you be careful radiographing dyspnoeic patients?
restraint needed may be fatal
what are the benefits of early imaging/TFAST?
determine potential causes and urgency of case
in cases of pleural effusion what should be determined?
bilateral or unilateral
volume of fluid
if need to do thoracocentesis
lab analysis
what should be determined in cases of pneumothorax?
is chest open or closed
unilateral or bilateral
volume of air
if thoracocentesis is needed
how do you assess thoracic FBs?
imaging
is it radiopaque or radiolucent
what needs to be determined as differentials in cases of soft tissue masses in the thorax?
normal structure with abnormal appearance, neoplasia or torsion
abnormal structure in thorax
diaphragmatic hernia
what are signs of trauma in thoracic patients?
skin damage
broken ribs
when can pneumothorax be seen?
with and without trauma
describe a closed pneumothorax
internal air leak from something in chest containing air (oesophagus, trachea, small airways)
very fast lung collapse
describe an open pneumothorax
external air leak
opening in the chest from trauma or iatrogenic causes such as surgery, diaphragmatic rupture, thoracocentesis complications
list signs of pneumothorax
dyspnoea
lethargy
cough
exercise intolerance
state diagnostic tests for pneumothorax
imaging
thoracocentesis
what should be determined in pneumothorax diagnosis?
if it is unilateral or bilateral
how are pneumothoraxs treated?
chest drain for conservative management of small air leaks that may heal
thoracotomy if big leak or not self sealing
list causes of thoracic trauma
accident - rta, fall, impaling
attack - dog, human, accident or not
list clinical signs of thoracic trauma
shock
dyspnoea
soft tissue damage - open wounds, bruising
orthopaedic damage to chest or body
how is thoracic trauma treated?
stabilised
surgery
list possible complications of thoracic trauma
infection
issues with healing
effusions
pneumothorax
etc
what affects prognosis of thoracic trauma?
injury severity
owners ability to fund treatment
define blebs
collection of air on the edge of lobes between lung and visceral pleura
define bullae
collection of air within lung lobes
list causes and signalment of pulmonary bullae and blebs
large breed deep chested dogs
concurrent disease
unknown cause
list clinical signs of pulmonary bullae and blebs
none unless ruptured
non-specific - lethargy, anorexia, exercise intolerance
respiratory - sudden onset dyspnoea, progressive tachypnoea, orthopnoea, coughing, pneumothorax
how are pulmonary bullae and blebs diagnosed?
radiography to diagnose pneumothorax, not lobe specific
CT for advanced assessment
how are pulmonary bullae and blebs treated?
50% respond to intermittent thoracocentesis or chest drain
thoracotomy/sternotomy for better localisation
lung lobectomy depending on number of effected lobes
what is the surgical approach to diaphragmatic ruptures?
abdominal
what are causes of diaphragmatic rupture?
blunt force trauma
increased intraabdominal pressure with closed glottis, diaphragm is weakest part
list clinical signs of diaphragmatic rupture
depends on severity, mild and vague to dyspnoea and shock
herniation of organs
torsion
dyspnoea
tachypnoea
orthopnoea
how is diaphragmatic rupture treated?
stabilise with oxygen
analgesia
IVFT
surgery - explore, reposition organs, removed badly torsed or unviable organs, repair diaphragm
place chest drains for iatrogenic pneumothorax
list causes of pleural effusion
CHF
FIP
pyothorax
tumours
haemorrhage
what are types of fluid that can be found in pleural effusions?
septic or non-septic exudates
modified transudate
transudate
blood
chlye
neoplastic effusion
etc
what is modified transudate?
fluid formed by leakage from normal/non-inflamed vessels
has high protien content
define transudate
passive fluid accumulation
list clinical signs of pleural effusion
dyspnoea
lethargy
cough
exercise intolerance
how is pleural effusion diagnosed?
imaging
bilateral or unilateral
thoracocentesis for SG of fluid, cytology, culture and sensitivity
how is pleural effusions treated?
CHF, cat pyothorax with medical management
pyothorax in dogs, diaphragmatic rupture with surgery
define pyothorax
pus in chest
list causes of pyothorax
bacterial infection - e coli in dogs, pasturella in cats
idiopathic - bites, extension from pulmonary abscess in cats
FB
oesophageal tears
pulmonary infection
list clinical signs of pyothorax
mild to severe
lethargy
inappetence
PUO
dyspnoea
how is pyothorax diagnosed?
cytology and culture of effusion
radiography
ultrasound
how is pyothorax treated?
systemic antibiotics
chest drain
lavage
sternotomy to explore, debride and flush
why do dogs typically undergo surgical treatment of pyothorax when cats is usually conservative treatment?
dogs have much higher incidences of FBs
define pericardial effusion
fluid around the heart
list causes of pericardial effusion
idiopathic
neoplastic
list signs of pericardial effusion
cardiac tamponade
depends on rate of fluid filling
why does severity of clinical signs of pericardial effusion depend on speed of development?
if it fills slowly the pericardium can stretch to accommodate larger fluid volumes
if rapidly fills pericardium cant compensate
how is pericardial effusion diagnosed?
radiography
echo
advanced imaging
cytology to see if neoplasia
how is pericardial effusion treated?
pericardiocentesis
pericardectomy
how does pericardectomy treat pericardial effusion?
stops tamponade and fluid becomes pleural effusion but unlikely large enough volume to cause any issues
list complications associated with pericardial effusion
recurrence
long term effusions cause adhesions
what determines prognosis for pericardial effusion?
underlying cause
what are the common types of pulmonary neoplasia seen?
malignant
secondary much more common than primary
list clinical signs of pulmonary neoplasia
vague
non-productive cough
haemoptysis (coughing blood)
dyspnoea
weight loss
exercise intolerance
anorexia
lameness/hypertrophic pulmonary osteopathy
describe hypertrophic pulmonary osteopathy
paraneoplastic syndrome caused by mets in legs leading to lameness
how is pulmonary neoplasia diagnosed?
bloods
urinalysis
cytology
advanced imaging
inflated imaging
how is pulmonary neoplasia treated?
palliative care
lung lobectomy if no mets
what determines prognosis of pulmonary neoplasia?
metastasis
histopathology
surgical margins
list surgical considerations for thoracic surgery patients
analgesia
manage hypothermia
IPPV
what needs to be monitored for thoracic surgery patients when not in surgery?
TRP
pain scoring
ventilation
how do you manage wounds following thoracic surgery?
prevent infection
general wound care
gels around drains to prevent air leaks
what are benefits of body bandages for thoracic surgery patients?
increase comfort
stop patient interference
reduce risk of infection
how do you care for thoracic surgery patients?
care for DUDE - IVFT, u cath if needed, feeding tubes
define thoracocentesis
puncture into pleural space for diagnostic and therapeutic purposes
what are important considerations for thoracocentesis?
prioritise patient safety
sterile prep
gloves and drape
what are the goals of thoracocentesis?
sample collection
drain fluid or air fully from pleural space
list equipment for thoracentesis
oxygen
LA
sterile prep
needle/butterfly cath/IV cath
3 way tap
syringes
extension set
kidney dish
sample tubes
refractometer
slides
what blood tubes are used for thoracocentesis and what are each for?
EDTA - EDTA
heparin - biochem
plain - culture
what are positives and negatives of using IV and butterfly catheter for thoracocentesis?
IV - can remove sharp, have to attach collection system so position may change, may kink or collapse
butterfly - have collection system attached so can do alone
describe the process of obtaining samples from thoracocentesis
use fist sample taken to avoid contamination
put in appropriate tubes
make fresh smear for cytology
check SG
what are the purposes of chest drains?
continuous or intermittent therapeutic drainage of the pleural space
why are intermittent chest drain placements not ideal long term?
risk increases with each placement
list reasons for indwelling chest drains
disease causing continued fluid or air production
large quantity of production
intermittent thoracicentesis not working
following thoracotomy
long term drainage needed
medication admin
what are considerations for indwelling chest drains?
patient temperament
patient tolerance
treatment plan
what can cause intermittent thoracocentesis not to work?
too high volumes being produced
too thick to come through butterfly cath
too high risk or causing lung trauma placing
what measures should be done following thoracotomy?
remove air/fluid from surgery
detect any air/fluid being produced from surgery complication or underlying condition
what conditions require long term drainage?
pneumothorax due to underlying disease
pleural effusion
what medications can be administered down chest drains?
LAs
saline to lavage pyo
antibiotics
chemotherapy
list types of chest drains
large bore
small bore
trocar placement
seldinger technique
what affects type of chest drains being used?
depends on type of medium being drained
what determines the size of chest drain used?
reasons for drainage
amount of fluid expected to drain
what are different methods of chest drain placement?
closed chest
open chest in surgery
where do you place chest drains?
uni or bilateral
if bilateral need on both sides if mediastinum intact
tip of drain cranioventrally to thoracic inlet
all fenestration in chest
what are the benefits of chest drain connectors?
allow efficient drainage without the risk of iatrogenic pneumothorax
how are chest drains secured in place?
sandal sutures - trocar drains
anchor flanges secures with simple sutures - seldinger
list nursing care for patients with chest drains
24 hour care
body bandage
buster collar
what are the advantages of trocar drains?
fenestrated
rigid so easy to position
lost of sizes available
good for air and fluid
large bore
dont collapse
clear so can check patency
what are disadvantages of trocar drains?
placed under GA
need SC tunnel to prevent air leaks
rigid so higher risk of lung damage and pneumothorax
needs careful training for placement and suturing
not comfortable
what are advantages of narrow bore/seldinger drains?
dont need SC tunnel
less invasive placement
air leak less likely
dont need to place under GA
easy to place and secure
versatile
more comfortable
what are disadvantages of narrow bore/seldinger drains?
more expensive
lots of parts to the drain
more likely to block
can be too long in small patients so kink or too much outside of chest
harder to place as flexible
list equipment needed for closed chest drain placement
sterile prep
anaesthetic equipment - LA or GA depending on drain
pre-measured drain
scalpel
forceps
needle holders
scissors
swabs
drape
3 way tap
syringes
extension set
kidney dish
suture material
what determines frequency of intermittent chest drainage?
RR and dyspnoea
usually done every 4-8 hours
when is continuous chest drainage normally used?
air leaks
what can be used to provide continuous chest drainage?
commercial drainage unit
heimlich valve - one way valve for air
list considerations for chest drainage
care suction wont collapse the tube or aspirate tissue
record volumes drained
how can you prevent infections with chest drains in place?
aseptic techniques
good bandage hygiene
culture before antibiotics
state analgesia that can be used for chest drains in hospital and at home
multi modal
hospital - LA, systemic opioids (care for respiratory effects), CRIs, paracetamol
home - NSAIDs, oral paracetamol
list some complications associated with chest drains
issues with placement
failure to drain
patient factors
iatrogenic issues
infection
what can cause issues with chest drain placement?
cant place
incorrect placement
ideally x-ray to check placement
list reasons for chest drains failing to drain
accidental removal
tube disconnection
obstruction
kinking
tube slipped out
how can patients interfere with chest drains?
removal of drain
damage to drain
list iatrogenic issues with chest drains
haemorrhage
haemothorax
heart or lung damage
premature removal so recurrence of issue
nerve damage
pneumothorax
pyothorax
seroma (due to high volume effusion, usually self resolves)
SC emphysema around skin incision
how do you manage infections associated with chest drains?
manage with aseptic techniques
antibiotics
may need to remove early
when should you remove a chest drain?
complications risk higher than benefit of drain
volume produced significantly reduced
recurrence unlikely
what should you do to prep for thoracotomy?
stabilise patient
surgical plan
how do you stabilise patients for thoracotomy?
oxygen
assess ASA
IVFT
bloods
what is included in surgical plan for thoracotomy patients?
drugs plan - analgesia, antibiotics
approach to surgery
kit
complications and management
what are benefits of intercostal thoracotomy?
less painful
can place chest drain with visual guidance
what should be considered when deciding to do intercostal thoracotomy?
which side and intercostal space
can it be treated with unilateral approach
describe how intercostal thoracotomy patient is prepped
clip from thoracic inlet to mid abdo
loosely tie front and back legs
keep sternum and spine level
what are the benefits of sternotomy for thoracotomy?
better for exploration and bilateral conditions
can place chest drain with visual guidance
when is sternotomy not useful to perform?
if dorsal thorax affected
do you prep patients for sternotomy?
clip from thoracic inlet to mid abdo
keep stable with cradle or sandbags
loosely tie legs out of way
what are considerations for thoracoscopy?
least painful
needs specialised equipment
limitations in procedures and visualisation
fully clip in case need to convert to open
can be in lateral or dorsal depending on procedure
list common thoracic surgery instruments
long handled forceps
scissors
needle holders
handheld or self retaining retractors
sternotomy instruments
what is a type of forceps for thoracic surgery and what are their features?
debakeys
atraumatic, fine dissection, clamping vessels
what are different types of clamps used for in thoracic surgery?
vascular/statinsky/soft palette clamps for vessels
right angle clamps for dissection
what retractors are used for thoracic surgery?
finchietto
gelpis
langenbeck
malleable
what sternotomy specific instruments are used?
chisel and hammer
oscillating saw
list other equipment for thoracic surgery
lap swabs
thick suture material
wire
suction
chest drain
tourniquet
pledget sutures
vessel loops
what are the types of electrosurgery?
monopolar
bipolar
what is needed with monopolar electrosurgery and why?
earthing plate to prevent burns
list examples of advanced electrosurgery
gen11
ligasure
harmonic
when is advanced electrosurgery used?
used instead of staples
can have various uses
expensive
define lung lobectomy
partial or total removal of one lung lobe
define pneumonectomy
removal of a lung
what makes patients manage well after a pneumonectomy?
remaining lung fills the rest of the chest
what are closure options for lung lobectomy?
sutures - slow, technical, higher risk of leakage
staples - quick, less risk of leaks, more expensive, technical
describe how to perform a leak test following lung lobectomy
fill chest with warm saline
IPPV and check for air bubbles, suction all fluid out once happy
describe the anatomy of the liver (location, lobes, attachment)
sits in cranial abdomen with 2/3 mass on midline
4 lobes - left (largest), right, caudate and quadrate, are divided into sublobes and processes
attached to diaphragm, right kidney, lesser curvature of the stomach and proximal duodenum
which main vessel runs through the liver?
vena cava
describe blood supply to the liver
recieves from hepatic portal vein and hepatic artery
blood leaves via short hepatic veins to the vena cava
highly vascular
what is the purpose of the hepatic portal vein?
carry blood from the digestive tract and spleen, rich in nutrients and 50% of oxygen supply
what proportions does the liver get blood flow from the vessels?
80% from hepatic portal vein
20% from hepatic artery
what is the purpose of the hepatic artery?
carry oxygen rich blood, providing 50% oxygen
describe how blood passes through the liver
portal and arterial blood mix in sinusoids in liver
drain into hepatic veins
leave via dorsal border into caudal vena cava
list functions of the liver
synthesis of albumin, globulin, clotting factors, glucose, cholesterol
clearance of ammonia, bilirubin, bile acids, drugs
metabolism of carbs, lipids, amino acids
production and activation of clotting factors
clearance of toxins (ammonia, drugs)
immunoregulation
GI function
storage of vitamins, fats, glycogen, copper
what can be the consequence of hepatic dysfunction on synthesis and clearance?
ascites
longer duration of albumin bound drugs
excess drug sensitivity
neurological signs
PUPD
anorexia
vomiting
what are the consequences of hepatic dysfunction on metabolism?
hypoglycaemia
lethargy
weight loss
what are the consequences of hepatic dysfunction on production and activation of clotting factors?
clotting issues
haemorrhage
what are the consequences of hepatic dysfunction on immunoregulation?
endotoxaemia
sepsis
what are the consequences of hepatic dysfunction on GI function?
weight loss
diarrhoea
list clinical signs of hepatic dysfunction
inappetence
lethargy
vomiting
diarrhoea
jaundice
ascites
hepatic synthetic failure - carbs, protein, fat, clotting factors
detox failure - encephalopathy, increased drug activity
what causes jaundice?
hyperbillirubinaemia and tissue deposition of bile pigment due to failure of routine clearance of bilirubin
what is pre-hepatic jaundice?
haemolysis causing too much bilirubin for liver to clear
what is hepatic jaundice?
failure of uptake, conjugation to water soluble form or transport of bilirubin by the liver
what is post-hepatic jaundice?
failure of excretion of bile due to cholestatic disease or biliary rupture
how does ascites occur?
fluid accumulation in abdomen due to hypoalbuminaemia and portal hypertension causing sodium and water retention
what causes detoxification failure in the liver?
hepatic dysfunction or PSS
what are the effects of detoxification failure in the liver?
failure of ammonia conversion to urea
failure of drug detoxification so longer effects
what is the effect of hepatic encephalopathy?
fore brain disfunction, is the behaviour mediator
list clinical signs of hepatic encephalopathy
lethargy
obtunded
pacing
circling
head pressing
seizure
coma
what worsens signs of hepatic encephalopathy?
high protein meal
GI haemorrhage
vomiting and diarrhoea
diuretics
what is the significance of the liver having large functional reserve?
clinical signs wont present until 70-80% functional hepatic tissue is lost
describe what happens to bile after it is synthesised in the liver
excreted into hepatic ducts which drain to common bile duct
if not digesting this goes via cystic duct to gall bladder for storage and concentration
in digestion bile leaves via cystic duct to common bile duct to duodenum
list functions of the biliary tract and bile acids
aid digestion and absorption of fats
neutralise gastric acid
inhibit gastric acid secretions to prevent intestinal ulceration
list diagnostic tests for liver disease
biochemistry
haematology
blood gas
blood glucose
electrolytes
dynamic bile acid testing
liver enzymes
bibirubin
blood clotting
urinalysis
US
CT, MRI, scintigrpahy
biopsies
list ways of managing liver disease
prescription diet
oral antibiotics
oral lactulose
describe a prescription diet for liver disease
contains levels of high BV proteins
restricted fat
copper restricted
antioxidant supplemented
why are oral antibiotics used for liver disease?
compensates for livers reduced immunoregulatory action of detoxification of pathogens in intestines
prevent endotoxemia
why is oral lactulose used in hepatic patients?
binds to ammonia so can be excreted in faeces
reduces risk of hepatic encephalopathy
list management that should be done for hepatic patients before taking to surgery
clotting times
IV antibiotics
planning GA drugs
IVFT
manage electrolyte imbalances
blood typing and cross match
general patient care
what tests should be done for clotting times before taking liver patients to surgery?
full coag panel
platelet count
APTT and PT
how often are liver patients effected with abnormal clotting times?
50%
how would you manage abnormal clotting times before taking liver patient to surgery?
treat with FFP or vitamin k to minimise risk of haemorrhage
why would you give IV antibiotics to liver patients before surgery?
bacteria is in the liver so prevents endotoxaemia and sepsis
how would you choose antibiotics for patients undergoing liver surgery?
culture liver, bile and gall bladder
give broad spectrum while waiting for results
what drugs should be avoided in hepatic patients?
any that undergo hepatic metabolism
how should you manage IVFT for liver patients?
account for additional losses and correct any electrolyte imbalances
why is blood typing important in liver patients?
significant haemorrhage a risk
may have clotting disorders
what are general patient considerations for liver patients?
water and toileting if PUPD
tempt to eat if anorexic
how can you take liver biopsies?
US guided percutaneous FNA
open or laparoscopic
what is the purpose of taking liver biopsies?
diagnosis
prognosis
what are advantages and disadvantages of US percutaneous FNA liver biopsy?
adv - least risky
disadv - poor diagnostic accuracy
what are advantages and disadvantages of surgical liver biopsy?
adv - more accurate and better samples, can grossly visualise
disadv - more risky and invasive
when is partial or complete liver lobectomy done?
mass removal
abscesses
liver lobe torsion
what are risks associated with liver lobectomy?
haemorrhage
liver failure
portal hypertension
define cholecystectomy
removal of gall bladder
define cholecystoenterostomy
rerouting gall bladder to duodenum
when are cholecystectomy and cholecystoenterostomy indicated?
biliary tract rupture
bile peritonitis
diseases causing extra hepatic biliary obstruction such as gall bladder mucocele, choleliths, pancreatitis, neoplasia
in gall bladder surgery, which part is better to try to preserve?
common bile duct better to keep than the gall bladder
what makes hepatic and biliary surgery challenging?
high risk surgery and GA
list peri-op considerations for hepatic surgery
hypotension, ideally monitor BP with art line
hypothermia
haemorrhage
IVFT
drug choices
ventilation
IV antibiotics
blood glucose
why are liver surgical patients prone to hypothermia?
liver is highly metabolic
open abdominal surgery
how should you prepare for haemorrhage during liver surgery?
haemostasis available
blood products
list post-op care for liver patients
intensive nursing for 24 hours, longer if biliary or PSS
analgesia
IVFT
antibiotics
diet management
parameter monitoring
BP
monitor for haemorrhage, hypotension
temperature monitoring
blood glucose
sepsis monitoring
check for bile leakage
mentation
PCV, TS, electrolytes, acid base
how many PSS are congenital?
80%
what are causes of congenital PSS?
65-75% extra hepatic, in small breed dogs (westie, yorkie, cairn)
25-35% intrahepatic, in large breed dogs (wolf hound, labs)
how many PSS are acquired?
20%
what causes acquired PSS?
secondary to other disease such as chronic portal hypertension
describe PSS
anomalous blood vessel connecting hepatic portal vein to vena cava/systemic venous circulation so portal blood bypasses the liver
list clinical signs of PSS
GI signs
LUTD
coagulopathies
slow growth
what causes PSS clinical signs?
reduced oxygen and nutrient supply to the liver
altered metabolism of fat and protein
low protein production
reduced detox
lower urea production and higher ammonia in urine
what is seen on labs in PSS patients?
low albumin
low cholesterol
high bile acids
high ammonia
describe how to do a bile acid stim test
12 hour fast to remove bile acids in the blood
take blood sample
feed
retake blood sample 2 hours later
use serum gel or plain tube
what causes acute liver disease?
toxins
infection
list nursing considerations for acute liver disease patients
manage encephalopathy
give lactulose
monitor electrolytes
anti-emetics
blood glucose
coagulopathies
antioxidants if needed
how is PSS treated?
hydrate and regulate blood potassium
restrict protein
lactulose
antibiotics to minimise ammonia by gut flora
surgical closure of the shunt
what are types of chronic inflammatory liver disease?
sterile or infectious
what causes sterile chronic inflammatory liver disease?
copper or idiopathic for dogs
lymphocytic cholangitis in cats
what causes infectious chronic inflammatory liver disease?
cholangitis/inflammation of bile duct system
cholangiohepatitis/inflammation of the bile ducts, gall bladder and surrounding liver tissue
leptospirosis
FIP
how is inflammatory liver disease treated?
de-coppering therapy
antibiotics
diet modification
anti-oxidants
anti-inflammatories
choleretics
treating encephalopathy
ascites management
what can you use for decoppering therapy?
chelating agent (bonds to heavy metal)
zinc therapy
prescription diet
manage water source
how do choleretics work?
synthetic bile salts to stimulate bile flow
modulates inflammatory response in liver
list metabolic liver diseases
gall bladder mucoceles
feline hepatic lipidosis
what is gall bladder mucocele?
gall bladder fills with inspissated bile and mucus
what are the consequences of gall bladder mucocele?
asymptomatic
obstruct bile flow
ruptured gall bladder
how can you manage gall bladder mucocele?
medical management
surgical removal
how does feline hepatic lipidosis occur?
hepatocyte triglyceride deposition when anorexic, fat stores mobilise for energy and accumulate in liver
list predispositions for feline hepatic lipidosis
obesity
high fat diet
high carb diet
systemic illness
diabetes mellitis
what are the effects of feline hepatic lipidosis?
intra cellular fat accumulation
liver failure - encephalopathy, coagulopathy
death
how is feline hepatic lipidosis treated?
treat underlying disease
nutritional support with tube feeding
list signs of hepatic neoplasia
asymptomatic
hepatic and obstructive symptoms
rupture and haemoabdomen
how can hepatic neoplasias be treated?
primary - surgery
infiltrative - chemotherapy
metastatic - no treatment
list primary boas problems
stenotic nares
elongated and thick soft pallete
hypoplastic trachea
excess tissue in skin and airways
everted laryngeal saccules
hyperplastic tonsils
describe how boas patients present
loud breathing
snoring
exercise and heat intolerance
gagging
regurg
list compensatory mechanisms for boas
harder inspiratory pull
what are the consequences of boas compensatory mechanism
negative pressure in the throat, neck and chest causing secondary respiratory and GI issues
list secondary boas problems as a result of compensatory mechanisms
hiatal hernia
laryngeal collapse
reduced quality of life
regurg and aspiration
how is boas diagnosed?
physical exam
history
sedated exam
fluroscopy
barium swallow
CT
rhinoscopy
chest x-rays
list management of BOAS long term
dont breed, especially if clinically affected
minimal stress
avoid heat
manage weight
harness not collar
surgery to correct abnormalities
list pre-op considerations for boas surgery
bloods
asa grade
oxygen
minimal handling and stress
eye lube
prepare for regurg
what can lead to shorter prognosis of boas patients?
if severe disease
list surgical options for boas patients
shorten and thinning of soft pallette
laryngoplasty
laryngeal tie back
wedge resection of nostrils
what is laryngeal paralysis?
dysfunction of the laryngeal nerves causing paralysis of the larynx.
what is the consequence of laryngeal paralysis?
fails to open on inspiration and close on swallowing
can cause partial obstruction of upper airways
describe typical laryngeal paralysis presentation
large older dogs
exercise intolerance
cough
inspiratory stridor
respiratory distress
list first aid care for laryngeal paralysis
keep cool and calm
oxygen
possibly give butorphanol to calm and as anti-tussive
monitor for aspiration pneumonia, dysphagia (discomfort swallowing), megaoesphagus
steroids for reducing laryngeal oedema
how is laryngeal paralysis diagnosed?
laryngeal exam under sedation/ga
how is laryngeal paralysis managed long term?
weight loss
harness not lead
keep calm
avoid heat
dont feed dry food - dust can be inhaled
laryngeal tie back
raised feeding
no swimming
why is aspiration pneumonia a risk in laryngeal paralysis?
larynx cant close appropriately during eating and swallowing so food may be aspirated
list risk factors for tracheal collapse
small and toy breeds
obesity
middle aged
breeds - chihuahua, pom, shih tzu, lhasa apsos, poodle, yorkie
how does tracheal collapse occur?
tracheal rings lose rigidity, usually at the thoracic inlet
membrane of trachea sags making it hard for air to pass through to lungs
describe presentation of tracheal collapse
goose honking cough, worse with excitement, pressure on neck or hot weather, after eating or drinking
how is tracheal collapse diagnosed?
physical exam
x-ray/fluroscopy
bronchoscopy
what is grade 1 tracheal collapse?
25% loss of lumen
what is grade 2 tracheal collapse?
50% loss of lumen
what is grade 3 tracheal collapse?
75% loss of lumen
what is grade 4 tracheal collapse?
total loss of lumen
how is tracheal collapse managed?
oxygen
airway management
surgery
anti-inflammatories
anti-tussives
butorphanol
steroids
bronchodilators
no collar
weight loss
exercise restriction
harness
what surgeries can be done for tracheal collapse?
extraluminal ring prosthesis
intraluminal stenting
what does a tracheostomy bypass?
nares
pharynx
larynx
proximal trachea
list reasons for permenant tracheostomy
physical or functional obstruction of upper airway
upper airway compromised
stabilise patients in acute respiratory distress
laryngeal paralysis
BOAS
FB
laryngeal trauma
severe chronic respiratory obstruction
list nursing considerations for tracheostomy tubes
high levels of nursing care
maintaining airway
keep clean
keep comfortable
remove secretions
humidification
tube care
list potential problems with tracheostomy tubes
blockage
infection
water getting into tube
overheating (less efficient cooling)
how do you care for trach tubes?
initially every 15 minutes then every 4-6 hours when stable
monitor respiration, dyspnoea, cyanosis
issues with stoma site
coughing
discharge
routine suctioning
describe how to suction trach tubes
pre-oxygenate
aseptic technqiue
use long soft catheter no longer than tip of trach, move in circular motions while suctioning and withdrawing for 15 seconds
light and intermittent suctioning
how do you manage blocked trach tubes?
change inner lumen if can be removed
full removal is aseptic, using stay sutures to keep site open and place new tube
why is humidification needed for patients with trach tubes?
trach bypasses URT humidification
drying can damage muscosa, cause inflammation, irritation, thick mucus and dehydration
how do you humidify air for patients with trach tubes?
humidification filter
nebulisation
can do small volumes of sterile saline down tube
list equipment needed for nasopharyngeal FB removal
rhinoscope (flexible)
crocodile forceps
flush
list risks of nasopharyngeal FB removal
damage to nasopharynx
bleeding
incomplete removal of FB
aspiration
what is peri-op care for nasopharyngeal FB removal?
oxygen
close monitoring
analgesia
anti-inflammatories
what is aspergillosis?
fungal infection - aspergillus fumigatus
commonly of the nose where fungus produces alfatoxins causing inflammatory response and destruction of bone and turbinates
what can cause secondary aspergillosis?
FB
how can aspergillosis become systemic?
if fungus enters the body via respiratory tract and travels in the blood
list risk factors for aspergillosis
dogs with immune compromise as is opportunistic
meso and dociocephalic dogs more prone
list clinical signs of aspergillosis
nasal discharge
epistaxis
sneezing
nasal pain
nasal depigmentation
less commonly facial deformity, stertor or CNS signs
how is aspergillosis diagnosed?
rhinoscopy
tissue biopsy as fungus not in nasal discharge
MRI, CT to see turbinate destruction
bloods are non specific
list risks of aspergillosis diagnosis and treatment
epistaxis
aspiration
less access to head for GA monitoring
how is aspergillosis treated?
topical antifungal into nostrils and sinuses sealed in
turned every 15 minutes for hour for full contact
suction out
debride
why is aspergillosis not treated with oral meds?
not effective
systemic effects
list post-op care for aspergillosis
cold pack on nose
analgesia
keep patient calm
monitor respiration
used to be standard post op care for ortho patients and how has it changed?
6-12 weeks cage rest, but now involves more rehab
how can understanding the healing process help the post-op recovery process?
means you can avoid excessive strain and stress while challenging tissues in recovery to encourage return to normal function
list the stages of surgical recovery
post operative
regeneration
remodelling
what is post operative phase of recovery?
24-72 hours
pain, oedema, healing tissues
what treatment is done during the post-operative phase of recovery?
analgesia
cryotherapy
rest
non-weight bearing movement
what is the regenerative phase of recovery?
day 5 to 3 weeks
new collagen fibres forming for soft tissues
bone calluses forming in ortho
important not to disrupt these processes
how is the regenerative phase of recovery managed?
controlled lead exercise
PROM and AROM
what is the remodelling phase of recovery?
6 weeks to 1 year
consolidation - cellular to fibrous tissue, strength and alignment for ST
maturation - vascularity and metabolic rate returns to normal at 10wks to a year for ST
remodelling - reunion of bone
when can active exercise start in recovery?
remodelling phase
what is the main risk for cruciate disease?
obesity
other cruciate gone
what management can be done pre cruciate disease surgery?
weight management
hydrotherapy
list treatment options for cruciate disease
small dogs can leave
TTA/tibial tuberosity advancement
TPLO/tibial plataeu leveling osteotomy
lateral suture
what is the disadvantage of not treating cruciate disease?
very prone to OA
how do you rehab after cruciate surgery?
active exercise
hydro
slow return to normal
what affects choice of treatment for cruciate disease?
patient size
client preference
clinician preference
what effects fracture treatment options?
degree of fracture
site
any disease affecting healing
soft tissue damage
open wounds
how do you rehab following fracture repair?
analgesia
restricted exercise until callus formed
cold compress
encourage use and ROM slowly
supportive dressing if needed to stabilise and reduce pain
what are considerations for ex-fix of fractures?
can be hard to apply treatment
can massage/PROM
need to extend distal limb as naturally flex in fixator
what are considerations for joint surgery?
very painful
manage with experienced staff and consequences can be severe if go wrong
list post op care for joint surgeries
analgesia
cryotherapy
pressure dressing for pain and swelling
PROM
massage
slow and controlled movement
keep calm
what are the benefits of PROM?
maintain ROM
maintain blood and lymphatic circulation
stimulate sensory awareness
how do you manage patients following tendon surgery?
rest
NSAIDs
PROM after 3 weeks
limited exercise for 6 weeks
list goals of recovery following ortho surgery
weight bearing
active ROM to be good
muscle building to support limb and function
what are the benefits or rehab?
assists return to function
minimise stress on surgical site
what are considerations for rehab following ortho surgery?
need to fully understand the condition
subjective and objective process
altered and assessed for healing
ensure pain management throughout
how to manage ortho patients pre-surgery?
cryotherapy to manage swelling
support dressings for swelling and analgesia
weight bear if possible to minimise muscle atrophy
analgesia
assess lifestyle and other conditions
what are the benefits of cryotherapy?
vasoconstriction
analgesic effect
reduced oedema
how do you perform cryotherapy?
15 minutes 3x daily
no direct contact
what are the benefits of heat therapy?
increase blood flow and elasticity
why should you be careful of using heat therapy?
can cause burns especially if has reduced sensation
what are the benefits of massage?
increased blood flow and oxygen supply
removes waste products
muscle works more efficiently and less painful
calming
aid venous and lymphatic return
mobilises adhesions
prepare for exercise and physio
recovery after exercise
list assisted exercises
standing
weight shifting
balance boards
swiss ball
muscle stimulation
slow walks
stairs
sit to stand to sit
wheel barrowing
dancing
hydro
why is communication needed for rehabilitation of patients?
details of progression and treatment
make sure everyone involved knows whats going on
define incision
clean sharp cut through full thickness skin
define laceration
jagged cut/tear to the skin, damages deeper tissues
define abrasion
superficial skin damage caused by friction parallel to the skin surface, doesnt extend deep into the dermis
define avulsion
injury where tissue is separated from underlying tissues such as ligaments, muscle or skin
define contusion
bruising
underlying damage to capillaries
define crush injury
tissue has been compressed causing direct tissue injury or secondary injury from damage to blood supply
define haematoma
blood vessel damage underneath the skin causing blood accumulation
define puncture
deep penetrating wound
list possible causes of puncture wounds
bites
gunshot
stabbing
grass seed
insect bites
define shearing injury
when tissue is damaged as layers move over each other
what can cause bite injuries
cat
dog
adder
what are the consequences of adder bites?
rapid inflammation and tissue necrosis
list types of burns
thermal
chemical
electrical
radiation
define degloving injuries
skin is removed from a limb or tail like a glove
what are the two types of degloving injuries?
mechanical
physiological
how does mechanical degloving occur?
skin is pulled from subdermal attachments
how does physiological degloving occur?
skin necroses and sloughs due to damage to blood supply
define desiccation
dried out
define eschar
scab
define excoriated
skin has been abraded/is raw/irritated
define exudate
fluid full of inflammatory cells
define hygroma
soft fluid filled mass on bony prominences
define maceration
breakdown of skin due to prolonged exposure to moisture
define seroma
fluid filled swelling often associated with dead space after surgery
define debridement
removal of necrotic or damaged tissues
define defect (in terms of wounds)
missing skin
what is a class 1 wound?
0-6hours
minimal contamination
what is a class 2 wound?
6-12 hours
microbial burden not reached critical level but are increasing
what is a class 3 wound?
more than 12 hours
wound infection present
what can wounds be contaminated with?
micro-organisms or debris
how can you describe the degree of wound infection?
superficial
deep
systemic
what determines treatment of wounds?
class of the wound
list considerations for patients presentingwith open wounds
full clinical exam
history
pre-existing conditions
meds
signalment - breed, species, age, sex
wound position
type of wound
class of wound
cause of wound
infection
temperament
client funds and expectations
how can steroids impact wound healing?
delay inflammatory cells, fibroblasts, collagen formation, scar contraction and epithelial migration
how does age affect patients with wounds?
older have reduced dermal thickness and lower microcirculation
how do cats and dogs differ in wound healing?
dogs have higher density of collateral sc trunk vessels
primary closure incisions have breaking strength 50% less in cats by day 7
cats have decreased skin perfusion in first week of healing
cats have less granulation tissue and slower epithelialisation
describe initial assessment done for patients with wounds
general exam and history
any trauma
vital signs
analgesia
first aid
monitoring
stabilisation
what happens in the inflammatory stage of wound healing?
haemorrhage
vasoconstriction for haemostasis and wound closure
vasodilation for increased vascular permeability and inflammatory cells to area
what stage of wound healing occurs at 0-5 days?
inflammatory
when does the debridement stage of wound healing occur?
day 0 onwards
what happens in the debridement stage of wound healing?
phagocytosis
migration of WBC
removal of cellular debris
when does the proliferative stage of wound healing occur?
day 3 to 4 weeks
what happens in the proliferative stage of wound healing?
fibroblasts proliferate
collagen synthesis
granulation
epithelialisation
contraction
what happens in the remodelling stage of wound healing?
wound contraction
remodelling of collagen fibres
scar formation
when does the remodelling stage of wound healing occur?
day 20 onwards
when is wound lavage done?
all wounds
what are the benefits of wound lavage?
reduce bacterial load - every hour earlier done bacterial load lower by half
visualise underlying tissues
rehydrate necrotic tissue
remove foreign material
remove toxins and cytokines
list considerations for wound lavage?
volume - 100-150ml/cm, 19g needle on 40ml syringe
pressure
isotonic warmed saline
sedate
analgesia
why would you not apply too much pressure for wound lavage?
may further penetrate debris
what steps are taken before wound lavage?
aseptic approach
clip and sterile prep, gel on wound to trap fur
list options for wound healing
primary closure/first intention healing
delayed primary closure/third intention healing/secondary closure
second intention healing/contraction and epithelialisation
what is primary closure of wounds?
immediate surgical repair
how is delayed primary closure done?
closed surgically when appropriate
what is secondary closure of wounds?
closure after long term treatment
how do you manage non-healing wounds?
keep monitoring, photos
swab for infection
consider patient factors and client compliance
assess dressings
what are proposed benefits of laser for wound healing?
pain relief
increased vascular activity
anti-inflammatory action
faster wound healing
nerve regeneration
rapid cell growth
why may laser not be used for wound healing?
not enough evidence for efficacy
list considerations for managing second intention healing
topical agents
dressings
bandage material
client compliance
cost
expertise
list general principles of managing second intention healing
non-introduction of anything harmful
tissue rest - movement restriction, minimal dressing changes
wound drainage
keep good circulation
cleanliness
what topical agents can be used in second intention healing?
honey
hydrocolloids
silver
negative pressure wound healing
why may clients not want to go through with second intention healing?
can be very expensive
painful
contractures may need revision surgery
what are the benefits of negative pressure wound healing?
reduces oedema and exudate accumulation so eliminates strike through
increased central wound perfusion and vascularisation to aid inflammatory phase and wbcs and enzymes to area
rapid contraction and wound healing
reduced dressing changes
what are the benefits of menuka honey for wound healing?
honey makes wounds more acidic which increases oxygen supressing proteases
better granulation as a result
shorter inflammatory phase
how do proteases impair wound healing?
destroy growth factors and proteins so excess amounts at wounds cause protein fibre and fibrin breakdown
fibroblasts and epithelial cells struggle to migrate across the wound leading to prolonged inflammatory phase
list considerations when using honey on wounds
higher exudate due to high sugar content causing osmolality effect
keep on for 3-4 days
consider cellular damage in healthy granulating wounds and epithelialisation
when do you stop putting honey on wounds and why?
after granulation has occurred to avoid over granulation
what could you use on granulated wounds and why?
hydrogel to aid healing and epithelialisation
what is over granulation?
excess scar tissue formation which limits epithelialisation
how is silver used for wounds?
not commonly
topical
antimicrobial effects so used in inflammatory phase
how do wet to dry dressings work?
overhydrate then completely dry wound bed
when removed debride the wound
what are the disadvantages of wet to dry dressings?
drying of the wound bed compromises healing
debridement is non-specific so can remove helpful cells and tissues
bacteria can penetrate
uncomfortable to remove
can leave fibres behind
what are the benefits of moisture retentive dressings?
allow healing as wound doesnt dry out
removes exudate
promote optimal function of cells for healing
lower infection rates
less frequent bandage change
lower overall cost
when should hydrogel dressings be used?
aid end stage of healing
applied to wound bed and covered with secondary non-absorbent dressing
list examples of hydrogel
intrasite
granugel
what is a hydrogel?
water based amorphous cohesive application
list examples of hydrocolloid dressings?
aquagel
granuflex
what are hydrocolloid dressings and how are they used?
carboxymethylated cellulose, pectin and gelatine that forms non-adherant gel
placed in contact with the wound
list examples of vapour permeable films and membrane dressings
primapore
melolin
what is the composition of vapour permeable films and membrane dressings?
sheet of absorbant material between two thin layers of film with small pores for movement of gas and fluid
why are vapour permeable membranes and films used at the end of wound healing?
not highly absorbent so used when less exudate
name a type of foam dressing
allyven
when are foam dressings used and why?
well absorbant for initial stages of healing
what is the composition of foam dressings?
hydrophillic dressings made of polyurethane foam
can be adhesive or non-adhesive
breathable film backing
what are considerations for applying bandages?
patient interference
comfort
secondary bandage concerns
changing
positioning
list issues associated with bandages
tightness
inadequate padding
dirty
wet
not resting
when are tie over dressings used?
hard to bandage areas
what are issues associated with tie over dressings?
strike through
contamination
how do you decide which surgical wound reconstruction option to do?
simplest choice possible
list surgical wound reconstruction options from most simple to most difficult
simple closure
subdermal plexus/pedicle flap
axial pattern flap
free skin graft
list pros of simple wound closure
simple
quick
easy
list disadvantages to simple wound closure
relies on accurate wound assessment
cant do if infected
cant do if non-viable tissue present
can have excess tension
breakdown occurs if inappropriately assessed
list cases most appropriate for simple wound closure
primary or delayed primary closure
full thickness defects
incisions
fresh, clean or clean contaminated wounds
little defects
little debridement needed
what are advantages of subdermal plexus flap for wound reconstruction?
simple and versatile
good for medium sized wounds
reduces tension on wound healing
list disadvantages of subdermal plexus flap for wound reconstruction
relies on accurate assessment
size limitations
can damage plexus
too big flaps can cause vascular necrosis due to inadequate blood supply
poor technique can cause vascular necrosis and plexus damage
what wounds are suitable for subdermal plexus flap wound reconstruction?
primary, delayed primary or secondary closure
fresh clean wounds
bandaged or being treated for a while and clean at point of surgery
any location
medium sized wounds
may have had prior debridement
what are advantages of axial pattern flap for wound reconstruction?
flap comes with good blood supply
longer and wider flaps possible than subdermal
rapid healing of chronic wounds possible
list disadvantages of axial pattern flap for wound reconstruction
complex procedure
flap necrosis could be catastrophic
good post op care vital
can have poor cosmetic results
what wounds are suitable for reconstruction with axial pattern flap?
secondary closure
clean at time of surgery
large defect areas
what are the two types of skin grafts?
sheet graft
punch graft
what are advantages of skin grafts for wound reconstruction?
punch grafts simple
sheet grafts good for large deficits
rapid healing of chronic wounds
when it fails the body is often triggered to heal without graft
what are disadvantages of skin grafts for wound reconstruction?
lower success rates
sheet grafts complex and need committed team and owners
needs healthy granulation bed
good post-op care vital
partial and complete failure not uncommon
what wounds are appropriate for skin grafts for reconstruction?
secondary wounds
limb wounds or areas flaps arent an option
how is simple closure of wounds done?
under GA or sedation using basic kit or staples
may need bandaging
describe how a subdermal plexus flap is performed
skin is elevated and dissected away from underlying muscles to preserve vessels
skins elasticity means skin can be moved to cover larger defecit, rotated or advanced depending on wound site and tension
what makes a subdermal flap possible?
there is a generous plex of small arteries and veins in subdermal tissues under the skin
list some specific subdermal flaps used
flank fold flap - inguinal wounds
elbow fold flap - axillary wounds
how does an axial pattern flap work?
flap of tissue used incorporates direct cutaneous artery and vein that supplies large areas of skin
is raised and moved to cover large defects
what are the advantages of axial pattern flap compared to subdermal plexus flap?
less chance of breakdown due to vascular necrosis
what needs to happen before skin grafts can be done?
healthy bed of granulation tissue present
how do skin grafts work?
skin grows to fill any gaps left by the graft
describe how sheet grafts are performed
skin is taken from other site, which is closed as primary wound, and holes made in graft before applying to wound and suturing in
how are punch grafts performed?
small punches of skin taken from other site on the body then applied to the wound and sutured in
list questions to ask before planning wound treatment
defect size
will it get bigger after debridement
how easy is healing going to be
any other issues
how much viable tissue
cause and type of wound
patient health
temperament
signalment
factors affecting healing
when is it going to surgery
how mobile is the area
how much spare skin
what are some patient factors that affect wound healing?
immunosupressive cases
steroids
poor nutrition
list considerations for wound treatment
what is the wound
cause of wound
patient
closure options
other treatments
location of the wound
how do you manage unstable patients with wounds?
protect wound from further damage while assessing and stabilising
what is the goals of wound healing?
minimise healing time
maximise function
consider cost
list client considerations for surgical wound healing
cost - surgery may be cheaper than bandaging
compliance for revisits and home management
practicalities of treatment
what are the 4 factors you are monitoring in wounds?
tissue
infection/inflammation
moisture
epithelialisation
what are you monitoring in terms of tissues in wound management?
viability
what are the types of viable tissue and what do they look like?
epithelial - healthy pale pink
granulation - red and moist, bleeds easily
what are the types of non-viable tissue and what do they look like?
sloughing - yellow/grey/brown
necrotic - black, hard and dry
what makes assessing viability of tissues in wound challenging?
hard to know whats viable
some may not present until few days later
why does necrotic tissue need to be removed?
promotes infection
when can you perform tissue debridement?
on presentation in stable patients and those undergoing primary repair
delayed in unstable patient, those with large wound management and bandages and undergoing delayed primary repair
how and when can you do wound debridement?
all at once if stable
gradually with surgery or bandages
what are the benefits of debridement?
remove necrotic tissue
promote healthy tissue granulation
remove contamination
what are the methods of wound debridement?
surgical
bandages
chemical
how do you prevent and manage infections in wounds?
clean if contaminated
debride if colonisation
topical antibiotics if local infection
systemic antibiotics if systemic infection
what indicates a wound has pre-existing infection?
age of wound
smell
discharge
what can affect risk of infection of wounds?
site of wound
wound aetiology
degree of contamination
wound lavage
when is inflammation good and bad during wound healing?
good if its granulation and healing
bad if its infection
how do you manage optimal moisture balance of wounds?
too moist if macerated or excoriated so dry out
too dry if dessiccated or or eschar present, moisten
what is wound discharge?
maceration or pus
what do you monitor for wound epithelialisation?
healing or not progressing
what is monitored when looking at epithelialisation of wound healing?
wound edges
measurements
photos
tissue around wound
progression
what can be seen for wound edges in epithelialisation?
pink and smooth is healing
dark, red or uneven are not healing
what are you observing when assessing tissue around the wound?
cellulitis
oedema
skin
how can you promote epitelialisation?
manage tissues, moisture and infection/inflammation
protect new epithelial tissue as prone to rub away
care with bandages as can compromise
how do you surgically debride?
sharp dissection to removal all contaminated necrotic tissue
how can you physically debride wounds?
adherent dressings that remove tissue when removed such as wet to dry
how can you chemically debride?
chemical substances such as intrasite to remove dead tissue
what are the key considerations when bandaging open wounds?
protect - self trauma, contamination, infection, dessication
provide - analgesia, immobilisation, pressure for swelling and haemorrhage, give topical meds
debride
moisture - maintain optimum moisture balance
list nurses roles in wound management
continuity
advocacy
nurse clinics
clinical audits
what do you need to advocate for in wound management cases?
client - cost, practicality, emotional support
patient - boredom, best treatments, complications
antimicrobial stewardship
define surgical site infection
type of hospital acquired infection, can present up to 30 days after leaving hospital
what affects risk of SSI?
patient
surgery
list consequences of SSI
poor healing
delayed healing
increased cost
revision surgery needed
not meeting expectations
compromise to patient welfare
pain
increased antibiotic use
what should you do if you suspect an SSI?
identify infection
assess extent
culture based antibiotics
good wound management
good infection control
how do you identify infections following surgery?
usually source is the wound
may be other source
what are the different extent of SSI?
incision site
deep into tissues
internally
systemically
why should antibiotics be culture based?
allows appropriate and effective antibiotics to be used
what makes good wound handling?
aseptic handling
keeping wound clean
when should you carry out good infection control?
pre, peri and post op
what are sources of introduction of SSI?
exogenous
endogenous
poor prep of equipment, patient and surgical staff
what are exogenous sources of infection?
sources from outside the body
how do endogenous sources cause infections?
from skins flora, normally not an issue but surgery or other disease can affect the immune system so can opportunistically cause infection
what predisposes patients to infection?
patient factors
environmental factors
treatment factors
what patient factors predispose for infection?
body condition
age - over 10 years have poor immune response, under 1 year have underdeveloped immune system
malnutrition - lower albumin so poorer response
immunosupression
endocrinopathies
remote infection - seeding in blood
opportunistic skin disease
recent op - foreign material such as sutures can develop bacteria
how can environmental factors increase risk of infection?
patient prep - clipper rash increases risk, hair in site, incorrect prep solutions
contamination
poor handwashing
non-aseptic handling
theatre - poor cleaning, inadequate ventilation (high temp good for bacteria
how can treatment affect risk of SSI?
time - infection rate doubles per hour of surgery
surgeon experience
poor antibiotic prophylaxis
emergency procedure - may not be ideal but die without
implants - FB, may not be sterile or contaminated
suture material choice
what is the most important part of infection control?
handwashing
when should you do handwashing?
before and after touching patients or surrounding
before aseptic tasks
before gloving
after exposure to contaminated materials
what is a clean surgical wound?
non-traumatic surgical wound
no opening to resp, GI, genitourinary or oropharyngeal tracts
what is infection rate for clean surgical wounds?
0-4.4%
when is infection likely to occur in clean surgical wounds?
over 90 min surgery
implants
inexperienced surgeon
what is a clean contaminated surgical wound?
surgical wounds involving entry to the resp, GI, genitourinary or oropharyngeal tracts
when drains are placed
what is infection rate for clean contaminated surgical wounds?
4.5-9.3%
what should you do in surgery for clean contaminated wounds?
antibiotic prophylaxis
what is a contaminated surgical wound?
open wounds
spillage of GI contents or infected urine
breakage of asepsis
what is infection rate for contaminated surgical wounds?
5.8-28.6%
how can you try to prevent infection in contaminated surgical wounds?
lavage
debridement
antibiotic therapy
what are dirty surgical wounds?
old purulent wounds
FB
faecal contamination
infected skin at surgical site
what surgeries should antibiotics be used for?
implants
surgery over 90 mins
clean contaminated, contaminated or dirty procedures
how do you choose antibiotics for surgical wounds?
culture
while waiting for culture can assume contamination is by staph or ecoli
how do you give antibiotics through surgery?
30-60 mins pre op
every 90 mins
stop within 24 hrs for clean surgery
what is the normal cause of hip dysplasia?
inherited developmental disease
list characteristics of hip dysplasia
laxity of hip joint
development of OA
describe common signalment for hip dysplasia
large and giant breed dogs
4-12months with hip laxity
adult with secondary OA
history of hindlimb stiffness
why is limping uncommonly seen in hip dysplasia?
often both hips effected
describe how dip dysplasia occurs
laxity develops in the joint capsule as 4-5 months allowing subluxation of the hip due to the round or teres ligament stretching/rupturing
what factors other than genetics can influence hip dysplasia occuring?
size of dog
rate of growth
diet
exercise
what are the consequences of laxity associated with hip dysplasia?
inflammation
increased joint fluid from inflammation
thickened joint capsule from inflammation
pain
femoral head flattens
new bone produced at margins of head and around neck
how do changes assoicated with hip dysplasia occur?
rapidly in first year while growing
OA and remoddleing occurs slowly
describe typical presentation for hip dysplasia
short stride - adduction more comfortable
lateral sway - movement without full movement of hip
bunny hopping - share load
stiffness
exercise intolerance
clunking hips
crepitus
pain on extension
muscle atrophy
list investigations done for diagnosing hip dysplasia
imaging - VD extended and lateral views to see femoral head position, subluxation and OA, can do frog leg
ortolani test
bardens hip lift test
when would you do frog leg x-rays for hip dysplasia and what is the disadvantage of this?
to determine if can use double/triple pelvic osteotomy
disadv - masks laxity
what is the benefits and negatives of ortolani hip testing for hip dysplasia?
assesses severity
not useful if have arthritis or full luxation
describe how ortoliani test determines if subluxation is present when testing for hip dysplasia
pushing down subluxates the hip and moving the femurs laterally relocates them and bringing back medially subluxates them again
what can be measured on ortolani test?
angle of reduction and subluxation
how is bardens hip test performed?
in lateral, trying to lever hip out of socket
what are the downsides of bardens hip test?
painful
list treatment options for hip dysplasia
conservative
pectineal myectomy
growth plate fusion/juvenile pubic symphysiodesis
osteotomies - double or triple
THR
femoral head and neck excision
denervation of the dorsal acetabulum
what is a pectineal myectomy for treating hip dysplasia?
cutting of a small muscle that puts pressure on the hip joint
what are the downsides for treating hip dysplasia with pectineal myectomy?
doesnt stabilise hip joint
OA will continue to progress
pain is likely to return
which surgeries for hip dysplasia can only be done in young dogs diagnosed under the age of 4 months old?
growth plate fusion
osteotomies
which surgical treatments are most commonly used to treat hip dysplasia?
THR
FHNE
when is conservative treatment done for hip dysplasia?
first line of treatment (unless very young going straight to surgery)
why is conservative treatment for hip dysplasia used in first line for most cases?
if young dog can allow joint to stabilise by fibrosis and bone remodelling
dogs likely to manage very well on this option
describe conservative management for hip dysplasia
short regular lead walks
hydrotherapy to maintain muscle mass
controlled food intake to restrict weight and growth
NSAIDs (or other meds)
when is surgical management indicated for patients with hip dysplasia?
significant clinical signs
fail on conservative treatment
name the prophylactic procedures for hip dysplasia
growth plate fusion
osteotomies
name the salvage procedures for hip dysplasia
THR
FHNE
describe the process of a growth plate fusion/juvinile pubic symphisiodesis for hip dysplasia treatment
closure of the pubic symphysis with electrocautery which creates thermal necrosis
must be done before 4 months of age
how does growth plate fusion/juvenile pubic symphisiodesis manage hip dysplasia?
causes acetabular ventroversion which increases dorsal cover of femoral head by acetabulum
improves hip congruency and decreases OA progression
what procedure is normally done at the same time as growth plate fusion/juvenile pubic symphisiodesis for hip dysplasia and why?
neutering
have genetic tendency for hip dysplasia
what are the benefits of growth plate fusion/juvenile pubic symphisiodesis?
minimally invasive
inexpensive
when is triple or double pelvic osteotomy suitable to be performed for hip dysplasia?
young animals 4-8 months old
no DJD
good clunk on ortolani
angle of reduction 25-35
angle of subluxation 5-10
how doe osteotomies treat hip dysplasia?
increases dorsal coverage of femoral head
corrects subluxation
restores weight bearing surface area
how is osteotomies performed for hip dysplasia?
pelvis cut/osteotomised into two or three pieces (pubis, ischium, ileum)
acetabulum is rotated and stabilised with bone plates and screws
what are complications associated with pelvic osteotomies?
screw pullout or breakage
why are revision surgeries with pelvic osteotomies uncommon even with complications?
maintain acetabular coverage
what are disadvantages of pelvic osteotomies in treating hip dysplasia?
doesnt prevent OA so may need salvage surgery later
when is FHNE performed for hip dysplasia?
end stage hips
arthritic hips not suitable for other procedures
small animals ideally
how does FHNE manage hip dysplasia?
prevents pain caused by rubbing
how does FHNE work?
removal of femoral head and neck causes pseudoarthrosis of fibrous tissue and bone filling the space
why is exercise and physio so important after FHNE?
to form mobile pseudoarthritis
maintain muscle mass
maintain ROM
what is denervation of dorsal acetabulum for hip dysplasia?
removal of nerves for pain relief
what happens in a THR?
femoral head and acetabulum replaced
what are the aims of THR?
pain relief
high level of function
list indications for THR
hip arthritis
hip dysplasia
what is a cemented THR?
cobalt chrome implants held in femur with cement
ultra high molecular weight polyethylene socket cemented in
cobalt femoral head attached
why is accurate placement so important for cemented THR?
revision difficult having to chip out cement or osteotomise femur to remove
describe uncemented THR
biological fusion
stem hammered into femoral diaphysis, bone grows into stem
acetabulum reamed out and implant hammered in
what is an important consideration for uncemented THR?
must have tight fit
what can determine use of cemented vs uncemented THR?
patient
preference
equipment availavle
what are the benefits of THR systems being interchangeable?
all can fit on common head
why may an uncemented acetabular THR system be prefered?
easier to place
why may a cemented femoral stem be prefered in THR?
less complications
how is implant size determined for THR?
templates on imaging
adjust as needed for patient in surgery
describe the surgical procedure for THR
craniolateral hip approach
femoral head excision
ream acetabulum
ream femur
cement acetabular
cement femur
place femoral head
reduce hip
bacterial swab
suture joint capsule
routine closure
post-op x-rays
why should you do bacterial swabs after THR?
ensure no infection present from surgery
what is the benefit of suturing the joint capsule following THR?
reduce chance of dislocation
why is it so important THR is kept completely sterile?
if implant is infected it needs to be removed and can be hard to then manage
how long does THR take for the bone/cement/implants to heal?
at least 6 weeks
list complications following THR?
5-15% incidence
fracture
loosening
dislocation
infection
subsidence
cement granuloma
neurological issues
state post op care for THR
6 weeks strict cage rest
lead walks only
no jumping
no slippery surfaces
must have x-rays before cleared to return to normal gradually
what is another name for elbow dysplasia?
developmental elbow disease
what is the most common cause of elbow lameness?
elbow dysplasia
list problems that can cause elbow dysplasia
ununited anconeal process of the ulna
OCD of medial humeral condyle
fragmented medial coronoid process of the ulna
asynchronous growth of the radius and ulna causing joint incongruity
describe typical signalment for elbow dysplasia
large breeds
6 months old
older if presenting with OA as secondary disease
males
why is it thought males are more prone to elbow dysplasia?
grow faster and bigger
describe typical history for elbow dysplasia
low grade lameness
bilateral
stiffness
what can be seen on physical exam in cases of elbow dysplasia?
elbow effusion
decreased ROM
pain on flexion and extension
lameness
pain
what x-rays can be used to help diagnose elbow dysplasia and lesions?
flexed mediolateral
cranio-caudal
neutral lateral for incongruency
why is CT more useful than x-rays for elbow dysplasia?
gold standard
x-rays may not be able to see primary lesions
more useful for FCP
which x-rays veiws are best for viewing the anconeous and osteocyte veiws in the elbow?
fully flexed mediolateral
which x-ray veiws are best for diagnosing OCD?
craniocaudal
what does the x-ray veiw cranio-caudal-caudomedial oblique show when looking at elbow dysplasia?
coronoid fragmentation
what x-ray veiws show the coronoids when looking at the elbow?
distomedial-proximolateral oblique views
what causes DJD of the elbow?
degenerative elbow disease/elbow dysplasia
what is effected in DJD of the elbow?
dorsal anconeal process and radial head
sclerosis of the ulna notch
flattened or burred FCP
increased humeroradial joint space
which breed is most prone to ununited anconeal process?
german sheperds
how does ununited anconeal process occur?
anconeal process should fuse at 4-5 months but when it doesnt elbow stability is compromised and OA begins
how is ununited anconeal process diagnosed?
fully flexed mediolateral radiographs
CT
why does ununited anconeal process occur?
short ulna relative to radius
pressure causes anconeal process to separate from the ulna
how is ununited anconeal process treated?
conservative
removal of anconeal process
proximal dynamic ulna osteotomy
lag screw fixation
how is beth so beautiful?
so pretty
how is treatment for ununited anconeal process decided?
age
displacement of anconeus
when is removal of the anconeus carried out for ununited anconeal process?
older dogs
what two treatments are done together with ununited anconeal process?
proximal dynamic ulna osteotomy
lag screw fixation
how does proximal dynamic ulna osteotomy treat ununited anconeal process?
relieves pressure on the anconeal process
allows lengthening of the ulna as the radius grows
removes shear stress on the anconeal process so can reunite with ulna metaphysis
what is the aim of lag screw fixation?
aim to heal
which treatment is gold standard for ununited anconeal procces?
lag screw fixation
what is the consequence of elbow incongruity?
cartilage wear
fragmentation of medial coronoid process
how can elbow incongruity be treated?
dynamic partial ulna ostectomy to lengthen or shorten ulna depending on relative length to radius
small portion of ulna excised for improved mediohumeral contact
what is the benefits of IM pin in dynamic partial ulna ostectomy and why is it not being fully stabilised beneficial?
pin provides some stability and pain relief
allows shifting over time to find best fit
what is OCD?
osteochondritis dissecans
what area of the elbow is affected by OCD?
medial condyle
what can be seen on imaging that indicates OCD?
subchondral bone defect on CC view
flattening of the medial humeral condyle
thickening partially detached flap of cartilage overlying subchondral bone defect
what disease can occur with OCD?
FCP/fragmented coronoid process
describe typical presentation of OCD?
young dogs 4-6m
lameness
effusion on elbow
how can OCD be treated?
conservative
surgical
what indicates the type of treatment for OCD?
size of lesion
degree of lameness
describe conservative management for OCD
restricted exercise for 4-6 weeks
NSAIDs
when is surgery done for OCD?
no improvement on conservative
very bad case
how is OCD surgically treated?
arthroscopy or arthrotomy and debridement of OCD flap
abrasion arthroplasty of subchondral bone to stimulate healing
what is the most common disease in dogs with elbow disease?
fragmented coronoid process/FCP
what can cause FCP?
hereditary
shallow ulna notch
short ulna leading to pressure on coronoid
describe typical presentation of FCP?
6-10 months
medium to large dogs
bilateral disease
stance abnormalities
other elbow diseases
how is FCP diagnosed?
x-ray to see secondary OA and osteophyte formation
CT - gold standard
how is FCP treated?
arthroscopic debridement in young dogs with little OA
medical management if OA well estabilshed
what determines treatment option for FCP?
size of lesion
severity of lameness
where is the most common location for FCP?
craniolateral aspect of medial coronoid process of the ulna adjacent to radial head
what do bone fragments in FCP often look like compared to healthy bone?
dead and yellow compared to well vascularised red live bone
what is the incidence of developing OA in dogs with elbow dysplasia?
all dogs
what determines if treatment is needed for elbow OA?
severity
clinical signs
what medical management can be done for OA?
NSAIDs
weight loss
hydro
physio
why is arthroscopy useful for cases with elbow OA?
assess severity and treatment
list goals of OA treatment
debride necrotic cartilage
remove sclerotic bone
neovascularisation
recruitment of pluripotent mesenchymal cells
how is debridement done is OA?
hand burr
hand currete
motorised shaver
how is cartilage replenishment encouraged in OA treatment?
exposed subchondral bone is treated with abrasion arthroplasty or microfracture
what is abrasion arthroplasty?
removal of loose cartilage down to subchondral bone with burr until bleeding
joint lavaged to remove fragments
how is microfracture done during arthroscopy?
angled micro pick pressed into subchondral bone until bleeding observed, joint then lavaged
where are problems usually in dogs with elbow dysplasia?
medial side compared to lateral
how are the two types of long bone osteotomy performed?
sliding humeral osteotomy to transfer weight to lateral aspect
abducting ulna osteotomy provides similar results as does proximal dynamic ulna osteotomy
what are the benefits of long bone osteotomy for elbow dysplasia?
shifting weight allows medial cartilage loss to heal
decreases medial compartment load
when are elbow replacements done?
too much cartilage loss or OA
what can be the result of complications from elbow replacement?
more surgery
arthrodesis
amputation
what has lowered complication rates for elbow replacements?
newer implants
what is elbow arthrodesis?
elbow fusion
when is arthrodesis performed?
final salvage procedure for end stage painful joints with unilateral lameness
what is the positive and negative result of elbow arthrodesis?
relieves pain
gait abnormality
what is the work up before elbow arthroscopy?
CT
when is elbow arthroscopy indicated?
explore joints
debridement
surface treatment
lavage for septic arthritis
assisted repair
minimise damage to surrounding tissues and structures
list advantages of arthroscopy compared to arthrotomy
decreased morbidity
more rapid recovery
decreased complications
improved outcomes
decreased surgical and hospitalisation times
list disadvantages of arthroscopy compared to arthrotomy
high level of skill needed
long learning curve
high cost equipment
increased client cost
what are the dimensions on an arthroscope?
1.9,2.4 or 2.7mm external diameter
lens angle 30 degrees
working length 8.5 or 13 cm
why do you use a camera not directly look down the arthroscope in surgery?
maintain sterility
what light is used on arthroscopes?
xenon or halogen
list equipment needed for arthroscopy
camera
camera mount
monitor
light post
canula
irrigation
egress system
hand instruments
power tools
electrocautery
fluid system
syringes for sampling
waterproof drapes
what is a canula for in an arthroscope?
for scope and instruments to pass through
protect equipment
maintain portals
what is the purpose of irrigation during scopes?
continuous flushing to inflate joint and keep blood free
how is irrigation performed in arthroscopes?
60mmHg of saline continuously flushed
what does the egress system do in arthroscope?
removal of fluid
how do you prep and position a patient for elbow arthroscopy?
full clip and prep in case need to convert to open
hang legs
waterproof drapes
dorsal for bilateral
lateral with elbow abducted and pronated for unilateral
describe how to carry out arthroscopy
white balance scope
aspirate joint fluid for sample and check positioning
inflate joint with saline
insert second needle for arthroscope canula, enlarge with scalpel
insert canula and arthroscope
connect egress tube
turn on fluids
inspect joint
insert instrument portal
how is instrument portal inserted for arthroscopy?
similar to putting in scope
what are the benefits of using an instrument portal in arthroscopy?
patent route for instruments
rubber stopper prevents fluid leaving
list different cutting instruments used in arthroscopy
knives
hooks
cutting forceps
burrs
osteotomes
crocodile forceps
what species does cruciate disease occur in?
common in dogs
can occur in cats
when is bilateral cruciate disease common?
after the first one has ruptured
describe forces in the stifle
gastrocnemius at fixed length
tibial plateau slopes caudally
tibia slopes forwards unless restrained by CCL
compressive forces by tibia and femur from weight and muscular forces are stopped by CCL
forces are proportional to slope of tibial plateau
what is average tibial slope angle?
24 degrees
how can you measure tibial slope angle?
on x-rays
what is common signalment for cruciate disease?
middle aged females
can affect any dog
what are causes of cruciate disease?
traumatic is rare
degenerative most common
inflammation such as rheumatoid arthritis
describe the purpose of the CCL
resist stifle extension
resist internal rotation
prevent tibia moving cranially
how is cruciate rupture diagnosed?
cranial drawer test
tibial thrust test
imaging
what is seen on cranial drawer test if the CCL is ruptures?
tibia moves cranially
what is seen on tibial thrust test if CCL is ruptured?
on flexion of the hock tibia moves cranially
what imaging is done for cruciate disease diagnosis?
orthoganol views
both stifles
what can be seen on imaging in cruciate disease?
joint effusion
increased fluid opacity
compressed fat pad
peri-articular osteophytes
what are the ways of treating cruciate disease?
conservative
intra articular replacement of ligament
extra articular replicate function of ligament
combination of two above
alteration of joint angle - TPLO, TTA, CCW
describe conservative management for cruciate disease
strict exercise restriction for 6-8 weeks
pain management
when is conservative management not appropriate for managing cruciate disease?
if over 15kg
meniscal lesions
no improvement in conservative management
why is intra articular replacement of ligament not commonly done for cruciate repair?
doesnt last very long
what is a extra articular replicate function of ligament?
lateral suture
describe the process of extra articular replicate function of ligament
arthrotomy
confirm diagnosis
debride cruciate rupture
check meniscus for tears
suture around femorofabella ligament, under patella ligament and through bone tunnel in tibial tuberosity - thick nylon secured with metal crimps
fascia lata repaired with modified mayo mattress suture
how does crimp clamp suture system work?
progressively increase tension and check for cranial drawer
placed in 3 places
list complications of extra articular replicate function of ligament for cruciate repair
suture failure
instability
infection
meniscal tear
anchor pullout
how does altering tibial slope angle treat cruciate disease?
removes need for CrCL
how does TPLO treat cruciate disease?
slope of tibial plateau prevents tibial thrust as femur cant slide down tibial plateau
describe the process of a TPLO
medial parapatellar approach
torn meniscus removed
tplo performed
round saw cuts proximal tibia, rotated on TPLO jig to keep in place with rotation and plated to make slope of 5-7 degrees
post op radiographs immediately after
how is patient positioned for TPLO surgery?
in dorsal
foot wrapped
body draped around leg
what equipment is used for TPLO?
stifle distractor
meniscal probe
osscilating TPLO saw
TPLO jig
pin driver
plate
screws
what happens to the steps created in the bone in tplo surgery?
remodel on healing
dont cause issue
list possible tplo complications
fibula fracture
peroneal nerve damage
popliteal artery trauma
tibial tuberosity avulsion fracture
patella ligament desmitis
pivot shift causing twisted leg gait
osteomyelitis
DJD
what is post op care for TPLO?
6 weeks strict cage rest
controlled return to normal exercise over 3 months
physio
hydro
6 week x-rays
when and why is cranial closing wedge used for cruciate disease?
small dogs as have small bones and steeper tibial angle
how is tibial tuberosity advancement done?
patella ligament taken to 90 degrees of tibial plataeu to eliminate tibial thrust
what is the medial meniscus important for?
stability
why is the medial meniscus prone to injury in cruciate rupture?
is attached to medial collateral ligament so is less mobile and gets crushed when cruciate is ruptured
occurs in 50% CCL ruptures
how are meniscal injuries treated?
remove ruptured portion
what is a common complication of cruciate surgery and why?
meniscal injury as can occur later after treatment for cruciate
what makes prognosis following cruciate rupture poorer?
older
meniscal tears
what are hematopoietic tumours?
liquid tumours
lymphoma
leukaemia
how are hematopoietic tumours treated?
chemotherapy
how is acute hematopoietic tumours recognised?
clinical signs directly relating to disease
how are chronic hematopoietic tumours found normally?
incidentally
what is leukaemia?
cancer of blood forming tissues
acute or chronic
what is lymphoma?
cancer of cells that make up any part of the immune system, b and t cells
what are the types of solid tumours?
sarcoma
carcinoma
what is a sarcoma and how is it classifed?
cancer of skeletal or connective tissue
classified according to parental tissue
where is osteosarcoma commonly found?
distal radius
top of femur
why is surgery for osteosarcoma normally palliative?
metastasis has normally occurred before presentation even if not detectable
what are the benefits of treating osteosarcoma even though its most likely palliative?
tumours are very painful
can extend life
what are palliative treatment options for osteosarcoma?
chemo
radiation
bisphosphonates
surgery to remove limb/tumour
what is a hemangiosarcoma?
cancer of the spleen, heart or blood vessels
how can hemangiosarcoma be treated?
chemo
surgery
what part of the body is effected by soft tissue sarcomas?
connective tissue
how are soft tissue sarcomas treated?
chemo
surgery
what parts of the body are effected in carcinomas?
tissue covering the body surface
tissue lining body cavity
tissue making up organs
what does adeno mean in naming tumours?
arises from a gland
what species is squamous cell carcinoma common in?
cats
where is squamous cell carcinomas normally found?
mouth
ears
nose
which area of squamous cell carcinomas are normally more invasive and can metastasis?
mouth
how can squamous cell carcinomas be treated?
surgery depending on location
radiation
chemo
what can induce squamous cell carcinoma?
sun
list types of round cell tumours
MCT
melanoma
list features of MCT
most malignant skin tumour in dogs
mast cells are involved in inflammatory and allergic mechanisms
manifests anywhere in the body in many ways
from benign to highly malignant
high rate of spread
in skin is hard and firm
under skin is mobile and soft
how may cats with MCT present?
splenic or GI presentation
how are MCT treated?
surgical removal, curative if not malignant and get good margins
chemo
radiation
how do melanomas typically present?
usually black
benign in skin
malignant in mouth or toes
painful and bleeding
what treatments can be done for melanoma?
surgery to improve quality of life
immunotherapy
how does immunotherapy hopefully slow the spread of melanoma?
melanoma vaccine contains human melanoma protiens, in the hope antibiodies will be produced to destroy future melanoma cells
define benign tumour
wont spread
slow growing
define malignant tumour
risk of spreading
define metastatic tumour
secondary tumour that grows in different location to primary
what are common locations for metastatic tumours to spread to?
liver
lungs
lymphnodes
what is PNS?
cancer associated alterations of structure or function not directly related to tumour or mets
how can you get rid of PNS?
treatment of the tumour
what can be the consequence of PNS?
mortality more than the tumour itself
what can the presence of PNS indicate?
return of the tumour
malignancy
list some of the PNS associated with lymphoma
hypercalcaemia
anaemia
neutrophillic leucocytosis
thrombocytopenia
what determines treatment choice of tumours?
type of tumour
staging of tumour
location
owner expectations
patient temperament
how is tumour sensitivity to chemo graded?
high
moderate
low
what does high sensitivity to chemo mean?
no surgical options
what types of tumours have high sensitivity to chemo?
lymphoma
leukemias
what types of tumours have moderate sensitivity to chemo?
high grade sarcoma
MCT
what is a moderate sensitivity to chemo?
possibly surgical tumour
what is a low sensitivity to chemo?
surgical or other treatment more appropriate
what tumour types are low sensitivity to chemo?
carcinoma
melanoma
how can location of a tumour affect treatment?
may not be resectable
how can owner expectation affect treatment of tumours?
cost
outcomes
disfiguring surgery
how can temperament affect choice of cancer treatment?
ability to cope with surgery
ability to cope with chemo and repeated treatments
when can chemo be used for cancer treatment?
sole treatment
with other therapy
before surgery to shrink tumour
after surgery for any remaining cells
what determines efficacy of chemo for tumours?
sensitivity to chemo
how does radiation treat cancer?
causes radiation induced cellular injury, dividing cells are more susceptible
what are alternate therapies that can be used for treating cancer?
cyrotherapy
hyperthermic therapy
photodynamic therapy
immunotherapy
what are the different surgical options for tumours?
complete excision
excisional biopsy
incisional biopsy
trucut biopsy
FNA
what does complete excision of tumors achieve?
remove mass and locally invading cells
what does excisional biopsy achive?
debulking of mass but may leave local invasion
what are the purpose of incisional biopsy, trucut biopsy and FNA for masses?
diagnosis
what can be the results of surgery for tumours?
curative
debulking
palliative
preventative
what are examples of preventative surgery for tumours?
retained testicles
skin changes from sun damage
what are reasons for oncologic emergency surgery?
bleeding
pathological fracture
infection
bowel perforation
bowel obstruction
why are tumours staged?
find out how much tumour is present in the body
assess overall health
concurrent conditions
PNS present
inform likely treatment and prognosis
what system is used for tumour staging?
TNM
what does the t stand for in tumour staging?
primary tumour size
what does the n stand for in tumour staging?
lymph node involvement
what does the m stand for in tumour staging?
metastasis
what tests are done in tumour staging?
clinical exam
history
urinalysis
bloods - CBC, biochem, specialised bloods for patient specific
chest x-rays or CT - mets
abdo US - organ changes and mets
liver spleen and lymphnode aspirate as appropriate
echo - before doxyrubicin
MRI if neuro tumour
how are tumours graded?
histological findings
appearance under the microscope
mitotic index
level of cell organisation
evidence of invading blood vessels
why is tumour grading important?
determines prognosis
what is important to remember when treating cancer patients?
holistic approach
what is important when planning care for cancer patients?
ability model useful
assess pain
collect relavent information from obs and owner
assess and adapt care as needed
document everything
manage medical and nursing needs
what are general patient considerations for cancer patientsin hospital?
enrichment
may be hospitalised long time
manage anorexia cause
avoid food aversions
reverese barrier nurse as impaired immune function
care for infections
caution with chemo drugs and excretions
what is meant by acute abdomen?
any intra-abdominal disease that leads to acute onset of clinical signs due to inflammation of an organ, leakage of fluid from damaged organ or organ entrapment
how serious is an acute abdomen?
often life threatening
list clinical signs of an acute abdomen
increased RR and effort
tachycardia
thready and poor peripheral pulses
pale, tacky MMs, long CRT if shocked
injected MMs, rapid CRT if septic
hypotension
hypothermia
collpased or obtunded
hypersalivation
nausea
regurg
retching/vomiting
abdo pain
distended abdo
arrhythmia
list common differentials for acute abdomen
GDV
FB
gastric ulceration
perforation
intusucception
septic peritonitis
abdo trauma
mesenteric volvulus
acute hepatitis
billiary obstruction/rupture
neoplasia
pancreatitis
splenic mass
splenic torsion
AKI
pylonephritis
urethral tear
uroabdomen
pyometra
prostatitis
what can help determine likely cause of acute abdomen?
signalment
what is GDV?
gastric dilation volvulus
stomach dilates and rotates
lifethreatening and high mortality
list the effects of GDV
reduced blood flow to GI tract and spleen leading to necrosis and septic peritonitis
vena cava compression so reduced venous return, reduced CO and hypotension
CV effects
respiratory effects
GI effects
hypovolaemic shock
what type of shock is most commonly seen in GDV?
hypovolaemic
what is hypovolaemic shock?
low circulating volume so low venous return, SV and CO
what is distributive shock?
vasodilation, leaky vessels and activation of coagulation by cytokine release leading to reduced venous return, SV and CO
what can prevent GDV progressing to distributive shock?
fast treatment
what can be the consequences of distributive shock?
SIRS/systemic inflammatory response syndrome
sepsis
what is cardiogenic shock?
heart cant pump due to reduced preload or pressure on thorax, leads to low cardiac contractility and CO
what is obstructive shock?
increased pressure on vessels in the abdomen leading to low venous return, SV and CO
how do you stabilise GDV patients?
oxygen
IV catheter
pain relief
fluids
blood samples
catecholamines may be used
what are considerations for IV catheters for GDV patients?
big as possible
ideally 2
front legs if possible as peripheral vasoconstriction means reduced delivery from saphenous
consider central lines
what are considerations for analgesia in triage for GDV patients?
painful conditions
opioids good
care with NSAIDs for ulcer risk
how do you manage IVFT for stabilising GDV patients?
shock rate bolus, care of haemodilution
if very sick hypertonic saline for resus but not if dehydrated
what bloods are good for initial management of GDV patients?
blood gas for electrolytes, oxygenation, metabolic status - arterial better
PVC
TS
urea and creatinine
blood type
coags in case of DIC
what is DIC?
disseminated intravascular coagulation
when are catecholamines (noradrenaline, dobutamine) used for acute abdo patients?
severe hypotension
fluids not enough
restore perfusion in septic patients
list useful diagnostics for acute abdomen patients
POCUS - confirm gas, haemoabdomen
x-ray for GD vs GDV
thoracic x-ray - aspriration
when is gastric decompression not possible?
twisted stomach
what can be negatives of gastric decompression?
can damage oesophagus or gastric wall
must be in fluid resus
can become shocky afterwards due to sudden release of endotoxins and inflammatory markers - do slowly
why is gastric decompression done?
relieve gastric contents and pressure
what are the two types of gastric decompression?
percutaneous decompression for gas
orogastric decompression for gas and fluid
what should you prepare for surgery for GDV?
crash kit, drugs calculated and drawn up
stomach tube for after untwisting
suction
IV fluids
lots of flush
warmed fluid for lavage
monitoring
lap swabs
surgical kit
self retaining retractors
tilt table
scrub and float nurse
why cant you use oesophageal stethoscope for GDV surgery?
need oesophageal access
list patient considerations for GDV surgery
hypotension - drugs ready, midaz, diaz, opiods, lidocaine, fentanyl
hypoxia
hypoxaemia
metabolic acidosis - get baselines for bicarb, base excess, pH , lactate, normally fluid corrected by may need to spike fluids
hypothermia
arrhythmias
regurg
what arrythmias are common in GDV?
VPC
VT
how do you manage arrhythmias in GDV surgery?
only treat VT
lidocaine bolus, CRI if effective
likely to resolve when untwisted
list anaesthetic protocols for GDV
pre-oxygenate
methadone and midaz premed, otherwise can cause too much CVS compromise
co induce with midaz and propofol/alfax to reduce post induction apnoea, VT, bradycardia
CRIs to reduce maintenance VAs or TIVA
what are peri-op considerations for GDV surgery?
keep bp above 60mmHg to prevent ischemia to organs
fluids for volume related hypotension
anticholinergics for bradycardia, atropine if under 40bpm, glycopyrulate in milder bradycardia
bradycardia likely vagally mediated due to pressure
more likely to see AV blocks
list post op monitoring and care for GDV
HR
MM
CRT
RR
hydration
bloods
ecg
BP
arrhythmias
IVFT
analgesia - CRI, paracetamol
stress management
UOP
signs of sepsis/sirs/DIC
aspiration pneumonia
nutrition
how do you manage nutrition in GDV patients post op?
tube feeding to control amount of food and frequency/volumes at one time
prevent over feeding
consider TPN or PPN if has central line
what is recurrence for GDV?
70-80% without gastropexy
4-10% with gastropexy
how can you educate clients on GDV?
warn of risks of recurrance
alter feeding to small meals
slow feeders
avoid stress
discuss prophylactic gastropexy during neutering for at risk breeds
educate on signs
what is the likely cause of sepsis in acute abdomen patients?
septic peritonitis
how do you manage septic peritonitis cases?
collect fluid samples and culture and sensitivity
broad spectrum antibiotics until culture back
early antibioitics to reduce risk of endotoxaemia
what is sepsis?
release of chemicals in bloodstream to fight infection, inappropriate and unregulated response to these chemicals triggers chnages that can damage multiple organ systems
describe anatomy of the thyroid gland
paired bilobed gland
isthmus between each side in humans, may or may not be in dogs and cats
caudal to the larynx
between 5th and 8th tracheal rings
ventrolateral to the trachea
right gland typically more cranial than the left
why is iatrogenic damage possible in thyroid surgery?
well vascularised
lots of neurological structures in the area
what is ectopic thyroid tissue?
thyroid tissue along the midline from the tongue to the abdomen resulting from path the tissue takes in embryonic development
list important nerve structures involved with the thyroid
caudal laryngeal nerve
recurrent laryngeal nerve
right vasosympathetic trunk
list important arteries involved with the thyroid
cranial thyroid artery
right common carotid artery
left cranial thryoid artery
left common carotid artery
left caudal thryoid artery
list surgical masses of the thyroid
(benign) adenomas
(benign) adenomatous hyperplasia
(benign) cysts
(malignant) carcinoma
(malignant) adenocarcinoma
what is meant by a functional thyroid mass?
actively produces thyroid hormone
why do cats with benign thyroid masses typically become hyperthryoid?
masses are normally functional
when are non-functional thyroid masses normally seen?
dogs
malignant masses
why are patients with non-functional thyroid masses normally presented with?
mass not tumour symptoms
which species are more prone to malignant thyroid masses?
dogs
list considerations for cats pre thyroidectomy
ASA status
systemic effects of hyperthyroidism
BCS
metastasis
CV
renal
occular
co morbidities
medical stabilisation
complications
why is BCS an important consideration for cats before thyroidectomy?
likely have muscle and weight loss due to hypermetabolism
how likely are metastasis to be seen in cats with thyroid tumours?
5% malignancy
71% adenocarcinomas have metastasis
what are concerns for CV system in cats before thyroidectomy?
hypertension
tachycardia
what can be effects of hypertension caused by hyperthyroid in cats?
pre-renal azotemia
retinal detachment
what is the result of an overactive thyroid?
increased metabolism
why are co morbidities common in thyroid patients?
likely older patients
list common co morbidities in hyperthyroid cats
CV
renal
increased GA risk
cachexia
arthritis
why is medical stability before thyroidectomy important?
improved ASA status, GA higher risk if unmanaged
how can you stabilise cats before thyroidectomy?
anti-thyroid meds to decrease HR
manage hypertension and stabilise heart rhythm with atenol
support renal function - diet, supplements, fluids
increase BW
list pre op thyroidectomy considerations for a dog?
ASA status
BCS
metastasis
co morbidities
stabilisation
complications
why do dogs have less systemic effects from thyroid tumours than cats?
normally are non-functional in dogs
what is more likely to cause effects in dogs who have thyroid tumours than the mass itself?
malignancy
how may BCS be effected in dogs with thyroid masses?
reduced due to effects of cancer
how common is metastasis in dogs with thyroid masses?
40% have mets
why is medical stabilisation not normally needed for dogs with thyroid masses?
masses are non-functional so have little systemic effects
which species has more invasive thyroid masses?
dogs
describe patient prep for thyroidectomy
wide clip from jaw to thoracic inlet and across neck
dorsal recumbency with sandbag under to elevate neck
stabilise straight
describe surgical approach for thyroidectomy
ventral midline approach
range of surgical techniques
may have parathyroidectomy
bilateral vs unilateral
may reimplant parathyroid tissue
list the different surgical techniques for thyroidectomy
modified intracapsular
modified extracapsular
what is the benefit of reimplanting parathyroid tissue?
allows neovascularisation so can become functional in 95% cases
what is the risk of reimplanting parathyroid tissue?
can seed tumour
list complications of thyroidectomy unrelated to surgical technique
GA
unmasking CKD in cats with functional masses
hypothyroidism
how can treating hyperthyroidism unmask CKD?
hyperthyroid increases BP which can maintain kidney function
once treated BP drops which can impair renal function
when is hypothyroidism prone post-op?
bilateral thyroidectomy
20% radioactive iodine treatment
list complications of thyroidectomy related to surgical technique
technique and skill
haemorrhage
seroma
laryngeal paralysis
horners
hypocalcaemia
recurrence
how does technique and skill effect thyroidectomy surgery?
unilateral vs bilateral vs bilateral staged
halsteads technique
why is haemorrhage common in thyroidectomy?
lots of vessels in area
dog masses are typically invasive
what can effect seroma formation after thyroidectomy?
size of mass
why is laryngeal paralysis a possible complication in thyroidectomy?
may damage recurrent laryngeal nerve
why is horners (neurological disorder of eyes and facial muscles) a possibel complication following thyroidectomy?
damage to sympathetic trunk
why is hypocalcaemia a potential consequence following thyroidectomy?
results from iatrogenic hypoparathyroidism as in thyroidectomy can damage or remove parathyroid tissue
how can you minimise chance of hypocalcaemia following thyroidectomy?
avoid parathyroids
give pre-op vitamin d and calcium
when is recurrence of thyroid disease common post op?
ectopic tissue present
intracapsular technique
malignant neoplasia
cats more common
what is the anatomy of the parathyroid glands?
2 pairs
cranial extracapsulars
caudal intracapsulars
what is the purpose of PTH?
increase blood calcium
when is primary hyperparathyroidism more commonly seen?
in dogs
what causes primary hyperparathyroidism?
mass signalling to increase PTH and calcium levels
how can primary hyperparathyroidism be medically treated?
ethanol injection
heat ablation
how is primary hyperparathyroidism surgically treated?
parathyroidectomy
what should you monitor post- parathyroidectomy?
monitor for hypocalcaemia
how does hypocalcaemia occur following parathyroidectomy?
parathyroid with the mass is overactive so other glands stop producing
when mass and parathyroid is removed low PTH so calcium is produced from the other glands
what type of masses are normally parathyroid masses?
benign functional adenomas
list considerations pre-op for parathyroidectomy
ASA status
systemic effects of hyperparathyroidism
comorbidities
medical stabilisation
complications
list systemic effects of hyperparathyroidism
hypercalcaemia
effects renal function
why are co morbidities common in hyperparathyroid pateints?
typically older animals presenting
what medical stabilisation is needed before parathyroidectomy?
improve asa status
reduce blood calcium if possible
support renal function
what can be done to try to reduce blood calcium?
high IVFT to dilute - careful management needed
how do you prep patients for parathyroidectomy?
same as thyroidectomy
describe surgical approach for parathyroidectomy
same as thyroidectomy
likely only removing one
magnification as tiny mass
intracapsular parathyroids may cause thyroid to be removed with it
why are parathyroid masses usually diagnosed on bloods?
too small to see on imaging
list complications of parathyroidectomy unrelated to surgical technique
GA
hypothyroidism post-op
complications of parathyroidectomy related to surgical technique
haemorrhage
seroma
laryngeal paralysis
horners
(all above are the same as thyroidectomy)
hypoparathyroidism
hypocalcaemia
list post-op care for parathyroidectomy
IVFT
analgesia - avoid opioids due to likely renal issues
monitor complications - renal, calcium
what is prognosis for parathyroidectomy?
usually good
transient hypocalcaemia can take days, weeks or months to resolve
list causes of iatrogenic hypoparathyroidism
unilateral thyroidectomy, bilateral thyroidectomy
unilateral parathyroidectomy
when is unilateral or bilateral thyroidectomy performed?
cat hyperthyroidism
dog thyroid malignancy
what are levels of thyroid hormones in hyperthyroid cats?
high T4
normal PTH
what are levels of thyroid hormone in dogs with thyroid masses?
normal T4
normal PTH
why is risk of hypocalcaemia and hypothyroidism low in unilateral thyroidectomy?
one thyroid and caudal parathyroid removed
may damage cranial parathyroids
why is risk of hypocalcaemia and hypothyroid higher in bilateral thyroidectomy than unilateral?
both thyroid and caudal parathyroids removed
cranial parathyroids may be damaged
when is unilateral parathyroidectomy performed?
primary hyperparathyroidism
dogs
what thyroid hormone levels are normally seen in dogs with primary hyperparathyroidism?
normal t4
high PTH
why is risk of hypocalcaemia high and hypothyroid low in unilateral parathyroidectomy?
remove 1 thyroid and 1 caudal parathyroid
cranials may be damaged or supressed
list signs of iatrogenic hypoparathyroidism
weakness
inappetence
lethargy
pytalism
pawing face
tremors
tetany
seizures
coma
death
when should you treat low calcium?
if see clinical signs
how can you manage low calcium?
vitamin D
monitor blood calcium
clinical signs
calcium admin
how can vitamin D increase calcium in the blood?
increases absorption from the GI tract
reduces loss through the kidneys
why should you give vitamin d 24-48hrs before parathyroidectomy?
takes that long to work
how do you monitor blood calcium levels?
ionised calcium not total
check 2-3 days post op
why is it important to only supplement calcium when very low or if clinical signs?
need to allow homeostatic mechanisms to work out, need some low calcium to encourage other parathyroids to start producing PTH
how can you give oral calcium?
elemental calcium divided into doses
gradually weaned off
how do you give IV calcium?
10% calcium gluconate slowly
bolus then CRI
careful as too much can lead to slow recovery of remaining parathyroids
monitor for arrythmias and bradycardia
avoid barcarb, lactate and phosphate in fluids - precipitates calcium
why can IV calcium not go SC?
sloughs skin
describe anatomy of the pancreas
right limb runs down the duodenum
lift limb next to the spleen
body close to pancreatic ducts and common bile duct
extensive blood supply
cats have accessory pancreatic duct
list surgical pancreatic conditions
insulinoma - endocrine
exocrine pancreatic neoplasia - exocrine
pancreatic abscessation and cysts - rare
list non-surgical pancreatic conditions
DM
exocrine pancreatic insufficiency
pancreatitis
what type of tumour is an insulinoma?
malignant carcinoma
where does insulinoma commonly metastasise to?
liver and LN
list clinical signs of insulinoma
lethargy
tremors
seizures
collapse
peripheral neuropathy due to hypoglycaemia
very low BG but not collapsed - occurs over time
how is insulinoma diagnosed?
bloods - glucose:insulin ratio
imaging
how do you manage insulinoma patients pre-op?
stabilise
feed q4-6 to maintain glucose
diabetic food
care for starving times
gentle exercise and regular
manage hypoglycaemia with feeding if coping
if crisis give sugar
why should you be careful in giving IV glucose to patients with insulinomas?
encourages insulin production so can push glucose even lower
how should you manage hypoglycaemic crisis in a veterinary setting?
oral glucose first
one off IV - 0.5-1ml/kg 50% dextrose diluted
glucose infusion - 2.5% solution
monitor BG
titrate as needed
stop glucose when improving
what are peri-op considertaions for partial pancreatectomy for insulinoma?
5% dextrose infusion in surgery
monitor glucose
gentle handling - reduce risk of pancreatitis
can be hard to find nodule
check liver for micrometastasis
what is the result of partial pancreatectomy for insulinoma?
removes source of insulin as long as all insulinoma tissue is removed
list post-op considerations for insulinomas
feeding
exercise
hypoglycaemia
drugs
complications
how do you manage feeding for insulinoma patients post-op?
same as pre-op
may need feeding tube
how do you manage exercise for insulinoma patients post-op?
same as pre-op
what can cause hypoglycaemia following partial pancreatectomy?
micrometastasis still causing insulin over-production
what drugs should be considered post pancreatectomy?
IVFT
analgesia
steroids to increase glucose
glucose
octreotide
chemo for residual tumour and mets
list possible complications following partial pancreatectomy
persistent hypoglycaemia
transient hyperglycaemia
pancreatitis
DM
list prognoses for insulinoma patients following partial pancreatectomy
stage 1 - survive 2+ years
stage 3 - survive 6 months
better than medical management alone
describe anatomy of adrenal glands
close to kidneys, caudal vena cava, renal vessels
outer cortex and inner medulla
which masses are found in adrenal cortex and what does this effect?
adenoma
adenocarcinoma
androgens, mineralocorticoid, glucocorticoid
what is a common medullary adrenal mass and what does this effect?
phaeochromocytoma
catecholamines - norepinephrine and adrenaline/epinephrine
list surgical adrenal conditions
adrenal mass
secondary adrenal enlargement
what types of masses can be present in the adrenals?
benign or malignant
primary
secondary to renal tumours
what causes secondary renal enlargement?
pituitary tumours
list clinical signs of adrenal gland disease
none - incidental finding
functional
haemoabdomen
what is the effect of functional adrenal masses?
likely have complex medical needs for stabilisation
surgery may not be best option
cover production from cortex in conns syndrome (aldosterone), cushings (cortisol), masculinising syndrome (testosterone)
over production from medulla in phaeochromocytoma (catecholamines)
what are the effects of phaeochromocytoma on the body?
throws out adrenaline
intermittent hypertension
other consequences
why can adrenal masses cause haemoabdomen?
spontaneous bleeding from mass
near lots of vessels
what are the different adrenal gland masses?
benign enlargements - adenoma
malignancy - adenocarcinoma, phaeochromocytoma - benign or malignant
malignant tumours can invade vena cava
list considerations pre-op for adrenalectomy
ASA status
systemic effects of adrenal mass
co morbidities
medical stabilisation
unilateral or bilateral disease
complications
list possible systemic effects of adrenal masses
conns syndrome causing hypokalaemia
cushings causing endogenous steroids, poor candidate for surgery due to impaired healing
phaeochromocytoma are unstable due to adrenaline releases
list medical stabilisation for adrenal surgery
manage potassium
meds to stabilise
phenoxybenzamine for phaeo to reduce HR and stabilise BP 2-3 before
what is the normal outcome for bilateral adrenal disease?
palliative care
euthanasia
why are adrenalectomies not commonly performed surgeries?
very challenging
haemorrhage common
thromboembolisms can develop post op
challenging recovery
20% mortality rate
list general considerations for adrenalectomy
functional vs non-functional disease
monitoring
intra-op complications
post-op complications
what monitoring is done in adrenalectomy surgery?
CV function
ECG for arrhythmias
BP
electrolytes
list potential intra op complications for adrenalectomy
tumour rupture
haemorrhage - blood type
tachycardia
arrhythmias
high or low BP
need to supplement mineralo or glucocorticoids in surgery
need for sodium or potassium supplements
list possible post-op complications following adrenalectomy
electrolyte abnormalities
high or low BP
adrenal insufficiency/iatrogenic addisons
delayed healing
pulmonary thromboembolism
sepsis
sirs
