Surgical Nursing And Analgesia Flashcards
Features of laryngeal paralysis
Can be congenital - severe polyneuropathy and unable to work or feed
Acquired - degenerative disease of the recurrent laryngeal nerve resulting in crico-arythenoideus dorsalis muscle incompetence
Diagnosis of laryngeal paralysis
Cervical and chest X-rays to check for megaoesophagus or consolidation
Ultrasound
Direct visualisation
Laryngoscopy with light GA
Emergency treatment of laryngeal paralysis
Oxygen Anti inflammatories but not NSAIDS ACP to sedate if necessary Tracheostomy Cool down the animal with fan or wet towels
Surgical considerations of laryngeal paralysis
Laryngeal tie back
Clip with angle of mandible in centre, half of next to corner of eye
No intraoral sutures
Partial laryngectomy will cause stenosis from inflammation
Post op care and prognosis of laryngeal paralysis
Local blocks instead of pain and sedation post op to prevent regurg/aspiration pneumonia due to open glottis
Careful with anaesthesia protocol
20-30% complication rate
Short term prognosis is excellent
Long term risk of aspiration, megaoesophagus, neuro conditions
Features of tracheal collapse
Dynamic obstruction of the upper airway
Tracheomalacia
Common cause of cough
Can affect cervical region, intrathoracic segent or both
Diagnosis of tracheal collapse
Radiography
Fluoroscopy - best method
Endoscopy with BAL sample
Treatment of tracheal collapse
Medical tx first - anti tussives, antisecretory, bronchodilators, antibiotics
Extra luminal prosthesis - syringe round trachea in cervical region
Intre luminal prosthesis - stent which can be used anywhere. Less morbidity but anti tussives to start as Fb in throat until surrounded by mucosa
Indications for permanent tracheostomy
Permanent UAO - laryngeal collapse, laryngeal neoplasia
Surgery considerations for a permanent tracheostomy
Ventral midline approach Good apposition Monofilament non absorbable Large stoma as will reduce over time Suture trachea to skin Skin fold plasty
Aftercare for a permanent tracheostomy
Keep clean
No collar
Suction
Nebuliser to reduce swelling and discomfort
Complications of a permanent tracheostomy
Mucous and secretions plug if not kept clean Stenosis/ stricture Obstruction Dehiscence Granulation tissue formation Skin fold obstruction Infection Impacts quality of life - no swimming
What is cholesteatoma
Epidermoid cyst with keratin debris Expansive lesion of the middle ear Locally destructive Non neoplastic Most commonly secondary to TECA-LBO Erodes bone
Symptoms of cholesteaoma
Head shaking Discharge Pain opening mouth Head tilt Facial palsy Ataxia Nystagmus Neuro signs - poorer prognosis
How to diagnose cholesteatoma
Radiographs - oblique views
CT - osteolysis, sclerosis, expanded bulla
MRI - expanded bulla with varying intensity
Treatment for cholesteatoma
Surgical resection to remove all abnormal tissue
Medical tx of antibiotics long term
Prognosis of cholesteatoma
Frequent recurrence
Neuro signs make prognosis worse as well as inability to open mouth and temporal bone lysis
What is primary secretory otitis media
Poor venting of et orifice in naso pharynx
VBO/TECA don’t treat the cause
Place plastic hollow tube to connect middle ear and external ear - grommits
Features of a subtotal TECA
Preserves most proximal portion of ear canal
Less dissection so less post op pain
Dogs and cats can have it
Vertical part of the external ear canal is dissected and cut proximally
Cartilage is sutured proximally
Dissection follows as per normal TECA
Symptoms of a para-aural abscess or fistula
Head pain Pain when opens mouth Head tilt Lethargy Swelling or draining sinus over surgical site Occurs 3-9months post op Only in dogs
Pathophysiology of para-aural abscess or fistula
Inadequate debridement of middle ear Not all ear cartilage is removed Osteomyelitis Parotid gland damage Can occur with TECA and cholesteatoma
Diagnosis of para-aural abscess or fistula
Can be FB or neoplasm Plain X-rays Contrast fistulogram CT and contrast MRI if showing neuro signs
Treatment of para-aural fistula
Medical - antibiotics
Surgical - lateral approach, central if confined to bulla or ventral to it
Complications of para-aural abscess or fistula
Facial nerve paralysis
Otitis interna
Head tilt
Sx is more successful than medical tx
Features of a ventral bulla osteotomy
Performed in cats to treat nasopharyngeal polyps
Can be done on dogs with recurrence of cholesteatoma or diseases limited to bulla but need to incise a lot deeper in dogs than cats
Principle of the chest drain
Drain placed in pleural space to remove air and fluid
Indications for a chest drain
Pneumothorax Chylothorax Haemothorax Pleural effusion Post thoracic sx
Equipment needed for chest drain placement
Clippers Prep Chest drain - soft and fenestrated and radiopague Sterile gloves and swabs Basic surgical kit Local blocks
How to place a chest drain
Lateral recumbancy
Clip 4th to 11th rib and prep
Local block 7-8th IC
Incision over rib 10 under skin and muscle to 7
How to care for a chest drain
Keep clean
Keep end covered if not continuous suction
Check stoma site for discharge and air leaks
Check drain for damage, leaks
Record output
Remove when production decreases
Cats tolerate poorly
What are the two types of chest drains
Intermittent
Continuous
Drainage of intermittent chest drains
Fluid and air
Every 2-4hours
Check for dyspnoea
Use a 3-way tap
Drainage of a continuous drain
Heimlich valve - valve closes on inspiration, passive system, dogs bigger than 10kg
Collecting bag and concertina
Different methods
Closed chest drainage system
Complications of a chest drain
Internal trauma Air leaks Obstructions Arrhythmias Infection
What is pneumothorax
Air in chest
Common cause of non traumatic pneumothorax is pulmonary blebs and bullae which burst open
Medical tx of thoracocentesis or thoracostomy tube placement
Describe the use of a chest drain for pneumothorax
Small lumen Fenestrate Soft Flexible Easily placed - no GA Continuous suction
What is pyothorax
Accumulation of septic pleural effusion
Gram negative or anaerobic bacteria
Treated my surgical exploration and debridement
Drainage and antibiotics
Describe the use of a drain for pyothorax
Wide lumen
Can place at the same time as the surgery
Place one on each side incase one gets blocked
Central position as draining heavy liquid
Flush chest
Continuous
Patient prep for thoracic sx
Foreleg to last rib clip - needs to be large
Cover drape
Legs extended cranially
Sandbags
Instruments for thoracic sx
Right angle lahey forceps
Pledgeted sutures
Satinsky clamp for atraumatic clamping of hilar bronchus
Mechanical staplers - gold standard for lobectomies. Staple proximally to lesion
What should the trolley be stocked with for foal emergencies
Syringes/ needles Blood tubes Glucose/ lactate reader Hibiscrub Spirit Catheter kit Clippers Fluids Feeding tube Oxygen Foal resuscitator
What is normal behaviour off the foal post parturition
Sternal - 2/3 minutes Suckle reflex - 30 minutes Standing - 60 minutes Standing and suckling - 2 hours Active/ playful - 6-7 hours
Healthy foal should avoid being caught and have a close affinity with the mare
What is a foals normal TPR
T 37.2-38.9
P 40-80bpm at birth which increases to 120-150 when trying to stand. First week 80-100bpm
R 60-80 at birth then 30-40
Rectal temp usually reflects that of environment so doesn’t indicate infection. Holosystolic murmers normal and disappear after 3 days
Clinical examination of a neonatal foal
Is there suck reflex
Look for entropion of eyelids and corneal ulceration
Look for colour changes in mm, coronary bands and ear pinnae which may indicate sepsis
Fungal plaques on tongue are a sign of ill thrift or systemic infection
Check for cleft palate and malocclusion of jaw
Milk at nostrils may show swallowing deficit - dummy foal
Palpate thorax for fractures
Check for abdo distension and hernias
Check umbilicus for swelling
Check genitalia - scrotal hernias, vulval petechiations
Monitor limbs closely for lameness from infection or contracted tendons
Extremities should be warm
Dilute urine should be passed frequently
Faeces should be pasty and toffee coloured once meconium passed
If born covered in meconium - stressful birth so monitor closely
How to tell if a foal is showing abnormal behaviour
Sick foals deteriorate rapidly
Low head carriage
Droopy ears
Appears to sleep standing up
Stand under the mare but will not latch or form a complete seal to nurse properly
Mares run milk which splashes onto foals face
What are the most common diseases in neonatal foals
Sepsis
Neonatal maladjustment syndrome - dummy foals deprived of o2
Prematurity
All 3 can occur together
How to nurse the recumbent foal
Keep sternal to improve oxygenation Well padded bed, lots of support Keep clean and dry Check eyes with fluoroscein for ulcers Change recumbency every 2 hours Blankets and hair huggers for warmth Beware bedsores Encourage to stand or walk with support Physio if can't walk
When to use enteral or parenteral nutritional support with a sick foal
Prematurity or diarrhoea will worsen if feed orally
Dummy foals can have NG tube placed and fed milk from mare as they’re not nursing properly
IV 5% glucose in isotonic fluids
Check for gastric reflux, GI sounds, abdo distension
45kcal/kg/day
What is failure of passive transfer and how to treat
No absorption of antibodies from the mare in the colostrum Check IgG levels >8g/L is a pass 4-8g/L is a partial failure < 4g/L is a fail
Boost with a plasma transfusion via NG tube if <6hrs old otherwise give IV
What is meconium impaction
Foal struggles to pass meconium
Obstructs rectum and colon
Common cause of colic
Commercial enema or homemade retention enema
When would you perform CPR on a neonatal foal
If born by assisted vaginal delivery following correction of dystocia or delivered by caesarean
What are the most common spinal disease categories in cats and dogs
Dogs - degenerative, traumatic, neoplasia, anomaolous
Cat - inflammatory/infectious, traumatic, neoplasia
What is a disc protrusion or extrusion
Disc extrusion - annulus tears and degenerate nucleus extrudes out to compress spinal cord
Disc protrusion - annulus bulges / protrudes which compresses the spinal cord - larger breeds
What colour should spinal discs be on MRI scans
White as they have water in them - become degenerate and turn black on imaging
What is cervical spondylomyelopathy
Canal stenosis Disc protrusion Facet hypertrophy Flávio ligamentum hypertrophy These all compress the cord
Facet joints not stable so disc degenerated - body makes more bone to stabilise but squishes cord in multiple directions
Poor prognosis
What is degenerative lumbosacral disease
Disc protrusion
Facet hyperplasia
Soft tissue proliferation
Subluxation
These impinge on caudal equina and directly or blood supply to it
Causes sciatic pain, affects urinary and fecal continence, v. Painful
What’s the most important thing to do when suspecting a spinal fracture or luxation
Radiograph two views
What are anomalous cysts
Sub arachnoid diverticula
Abnormal adhesion between layers of meninges
Causes a collection of CSF which compresses the spinal cord or causes inflammation in the cord
What is discospondylitis
Infection in the intervertebral disc and end plates of surrounding vertebrae
Compresses cord or causes instability with a compressive component
How do surgical diseases cause neuro signs
Through pathology of Laceration Compression Contusion Ischaemia Infiltration and dysfunction of cells directly or indirectly by affecting their environment
What spinal injuries can be medically managed
Laceration can be preventable
Ischaemia
Infiltration and dysfunction with drugs or radiations
How do you nurse a patient presenting with spinal laceration
Immobilise- spinal board
- Bandages to form a neck brace
- Spinal brace
How do you nurse a patient presenting with spinal ischaemia
Ensure ventilating appropriately - give o2 if necessary
Check cardiac output is sufficient
Ensure blood volume and blood pressure is appropriate - patient may be in shock
What are the 6 common surgical spinal procedures
Dorsal laminectomy Facetectomy Foraminotomy Hemilaminectomy Ventral slot Stabilisation/ fusion
What is a dorsal laminectomy
Removal of the laminae of the dorsal vertebral arch and dorsal spinal process allowing access to the dorsal spine
What is a facetectomy
Removal of the articular facet
What is a foraminotomy
Enlargement of an intervertebral foramen to relieve pressure on a nerve or nerve root
What is a hemilaminectomy
Removal of one half of the lateral vertebral arch to allow access and partial access to the ventral or dorsal aspect of the spinal column
What is a corpectomy
Lateral approach with removal of part of the vertebral body and end plates either side of a intervertebral disc aswell as removal of part of the disc
For thoracic/lumbar cord without going through thorax or abdomen
What is a ventral slot
Ventral approach in endplates of the vertebral body and removal of part of the disc in the cervical spine
What is stabilisation of the spine
Removing motion between adjacent vertebrae using implants and bone grafts
What is useful surgical kit for spinal surgery
Retractors - gelpi, odd leg gelpi, McKee Spinal burr and burrs Rongeurs Bone punch forceps Microrongeurs Periosteal elevator Nerve hook Curette Scaler Bone wax Surgicell PVA Duragen Surgical patties
What is crucial for recovery of spinal surgery
Physiotherapy
Team effort
Why is physiotherapy important
Prevents pressure sores Reduces pain Supports respiratory system Forms bond between rehabilitation team Promotes motor recovery
When do you start physio
24 hours post op
Nervous system needs to relearn by generating the movement
Only 10% spinal cord axons are needed to work
Where does physio act
Blood and lymph flow, relaxation, and promotes early ambulation
Maintains joint health, prevents muscle wastage, keeps tendons mobile
Improves core stability, retrains gait patterns, stimulates proprioceptive relearning
What physio actions are performed
Massage Passive Active assisted Active Proprioceptive Hot/cold therapy
Why is massage important
Venous and lymphatic drainage Analgesia Dermal stimulation Bonding Warm up
Why is passive range of movement exercise important
Joint health
Flexibility and elasticity
Gait patterning
Why is active assisted exercise important
Provides assistance during muscular contraction
Helps train the gait
Why are proprioceptive exercises important
Challenges the body recognition of limb position in space
What should be considered when making a physio plan
Expectation of the owner Temperament of the dog Previous activity Previous ailments Clients involvement of time and expertise Physical exam Neuro exam Disease process
Why can skin disease occur in spinal patients
Boredom
Sensory dysfunction - neuropathic pain causing self mutilation
Recumbancy - bed sores
Bladder / faecal dysfunction - leads to scalding
Why do skin sores develop
Lack of movement
Mechanical loading causing tissue compression
Ischaemia due to reduced pulsatile blood flow and venous blood return, repercussion injury and Bp anomalies following sx
Consequence of tissue break down - deep tissue first then skin - see wound after damage already caused
How do you prevent skin sores
Turning every 2 hours Good bedding - sling bed, porous mattress, non slip floors, inco sheets Bandage doughnuts around bony prominences Physio Inspect skin Barrier creams Relieve bladder often Avoid unnecessary bandages No tape on skin
How do you treat skin sores
Clean
Debridement
Antibiotics if needed
Bandage
How do you manage wounds from spinal surgery
Cryotherapy 15mins q4 48-72hrs
Dorsal approaches have skin movement and there is risk of layer separation and seroma formation
Care as may have loss of skin sensation
Why do many spinal patients have bladder impairment
Cells to bladder have nerves in s1-s3 to pons that cause contraction and relaxation of sphincter
What does lack of voluntary urination lead to
Uti from urine stasis
Bladder distension leading to atony where pacemaker fires but bladder cells can’t communicate with each other
Distension of ureters causing visceral damage
Skin sores
How to you manage the bladder and bowel of spinal patients
Manual expression x3 daily - only get 50% out but stops levels being dangerous
Catheter - indwelling or intermittent
Drug therapy to relax sphincter or contract bladder wall
What method of bladder management would be appropriate for a lower motor neurone bladder in a very aggressive dog that has urine scalding
Floppy bladder wall tone
Leaks urine constantly
Detrusor muscle stimulant
What is an upper motor neurone bladder
L1-L7
Increased tone to muscle wall but sphincter is tight
Difficult to express
Urine in lots of spurts as pressure is too great
What are the types of pain
Inflammatory - tissue damage
Neuropathic - dysfunction in transmission of nociception both peripherally or centrally
Acute
Chronic
Why do you need to monitor the respiratory system of spinal patients
Especially cervical lesions
Prone to hypoventilation, atelectasis, pneumonia
What are the 3 types of surgical site infections
Superficial incisional - skin and sub cut tissue
Deep incisional - deeper soft tissue involved
Organ / space infection - any other structures
What are th disadvantages of surgical infection
Poor cosmesis Delayed healing Increased cost to practice and owner Animal welfare More surgery to correct Client relationship may be damaged Increased use of antibiotics - resistance
What is a biofilm
Bacteria attach to a surface in communities which allows them to intersect and adapt to changing environments
Resistance to hosts immunity and antibacterial agents
Quiescent so give negative cultures so hard to diagnose
Implants are high risk for biofilm formation
How do you manage a surgical site infection
Antibiotics once culture and sens is back - give antibiotics before for what it’s most likely to be
Barrier nurse
Cover wound and debride
Record the bacteria, surgery, treatment and if it was successful
What factors may predispose a patient to infection
Patient
Environmental
Treatment
What are patient factors predisposing to infection
Geriatric or young animals have a diminished immune response
Obese animals - more weight on surgical areas like joints and less oxygen able to get through fat
Malnourished patients - decreased albumin levels in blood
Immunosuppression - chemo, steroids, diabetes mellitus
Remote infection - skin disease
Recent surgery
Rerioperative temperature - vasoconstriction
What are the environmental factors predisposing to surgical infection
Patient prep - separate area, don’t pre clip
Cross contamination - hand washing
Aseptic technique
Proper theatre conduct
Cleaning methods - damp dusting, disinfectants
Inadequate ventilation
What are the treatment factors predisposing to surgical infection
Surgical time
Experience of surgeon
Antibiotic administration
Use of a drain - benefits have to outweigh the risks
Emergency procedure
Surgical implants
Suture material - multifilament vs monofilament. Triclosan coated
What are the Halsteads principles
Gentle tissue handling Adequate haemostasis Preservation of blood supply Strict aseptic technique Minimum tension at wound closure Good tissue approximation - maintain good blood supply Obliteration of dead space
When to use antibiotics after surgery
Implants
When infection of wound would be catastrophic
Surgery more than 90 mins
Clean contaminated and contaminated procedures
Selection based on most likely contaminant
Start 30mins before sx IV
Likely to be no benefit continuing antibiotics post op other than already infected wounds, suspected infected wounds or bacteraemia
Post op care for surgical wounds
Cover for 24-48 hours and don’t change if strike through
Once fibrin seal has formed bandage no longer necessary
Avoid patient interference
Good drain management
Good nutrition - protein good for wound healing
Troy 7y MN poodle Retching post meal sudden onset Lying down and unwilling to go out HR 180, weak puls, pale mm RR 48' increased effort bilaterally Obtunded but appropriate Distended abdo What does this mean and what to do?
Severe hypoperfusion
IV catheter
IVFT
Oxygen
Blood sample- PCV/TS, haem, biochem, clotting times
Opiates for analgesia- methadone, fentanyl, morphine - sedative effect
Radiographs
What are the risk factors of GDV
Breed Body shape Age Anxious temperament Diet composition Number of meals Speed of eating
What are the local and systemic effects of GDV
Local effects on the gastric wall and spleen Systemic effects - reduced venous return - reduced cardiac output - hypotension - poor tissue perfusion - acidosis/inflammatory indicators - ischaemic reperfusion injury Sepsis
How is percutaneous decompression done
14-16G catheter
Point of maximal gaseous distension
Removes gas only
Must have ex lap soon afterwards - examine site of needle penetration
How is Oro-gastric decompression done
Can be done in conscious dog Measure tube Place bandage in mouth as gag Pass tube Fluid and gas
What is the aim of surgery to correct GDV
Gastric decompression and repositioning
Gastroplexy
Assessment of viability of abdo organs and resection of devitalised tissue
What anaesthetic plan would you have for a patient with GDV
Opiates and maybe diazepam Induction Iso Avoid nitrous oxide IVFT Antibiotics
Apart from gastric necrosis what is also associated with GDV
Splenic torsion
Why perform a gastroplexy on GDV patients
No gastroplexy means 80% mortality
More chance of recurrence if don’t do
Use incisional, belt loop or tube technique
What is the post op care for a GDV patient
Monitor parameters PCV / TS Urine output ECG / Bp IVFT Opiates NSAIDs when normotensive, normovolaemic and eating
Complications of GDV surgery
Arrhythmias- VPCs, caused by myocardial injury, electrolyte imbalance. Asses effect. Lidocaine 1-2mg/ bonus then CRI
Hypotension/ hypoperfusion
Aspiration pneumonia
Abnormal gastric motility - metoclopromide, gastroprotectants
Gastric necrosis
Sepsis
How can you prevent GDV and what advice to give to owners
Breed predisposed - elective sx? Laparoscopic gastroplexy Prevention better than cure Warm of risk of recurrence Feed multiple times daily Avoid stress
What do the thyroid glands do
Produce thyroxine which has metabolic effect on all organs
What are the clinical signs of hyperthyroidism
Polyphagia Weight loss PUPD increased activity V+/D+ Goitre - swelling in neck
What other diseases are associated with feline hyperthyroidism
Heart disease - tachycardia
Kidney disease - often masked by hyperthyroidism
What are the treatment options for hyperthyroidism
Medical - methimazole to decrease thyroxine production
Surgical - thyroidectomy
Radioactive iodine treatment
What is the aim of a thyroidectomy
Removal of one or both thyroid glands
Preservation of parathyroid tissue to avoid post operative complications - dissect around it
Stabilise medically before sx
Post op care for thyroidectomy
IVFT Analgesia Monitor renal function - avoid NSAIDs Watch out for laryngeal paralysis Hypocalcaemia
Why is hypocalcaemia a risk for thyroidectomy patients
Inadvertent removal or damage of parathyroid glands
Monitor for 2-7 days
Check ionised calcium
Seizures, muscle twitching, facial pruritus
Treatment of hypocalcaemia
10% calcium gluconate 0.25-1.5ml/kg slow IV
Calcium drip 10ml calcium gluconate in 250 hartmanns 60ml/kg 24 hours
Oral vit D and calcium
Taper medication over 4 weeks and monitor ionised calcium
What is the anatomy and function of the parathyroid glands
Pair of parathyroid glands for each thyroid gland
Secrete parathyroid hormone
Cause increased calcium in the blood and decreased phosphorous
What are the features of parathyroid tumours
Older dogs
Adenoma
Increased secretion of parathyroid hormone and loss of normal inhibition
Increased ionised calcium
Diagnosis of a parathyroid tumour
Hypercalcaemia
PUPD
Parathyroid mass on ultrasound
Treatment of parathyroid tumours
Diuresis for high calcium - IVFT saline
Diuretic
Parathyroidectomy
Partial thyroidectomy
What is the pancreatic endocrine function
Beta cells produce insulin and glucagon
Regulates glucose metabolism
Insulin decreases blood glucose levels and causes storage of glucose
Features of an insulinoma
Carcinoma of endocrine pancreas Aggressive Secretes insulin Causes hypoglycaemia Dogs Weakness Seizures Ataxia Muscle tremors
Diagnosis of hypoglycaemia
Bloods Wipples triad- clinical signs associated with hypoglycaemia - fasting glucose <2.2mmol/l - improvement in signs following feeding or glucose administration Increased serum insulin Imaging for metastasis Ultrasound CT
Treatment of insulinoma
Emergency treatment - sugar solution, glucose IV 0.25g/kg
Medical management - frequent meals, glucocorticoid steroids, diazoxide
Surgery - partial pancreatectomy with 5% dextrose infusion to prevent hypoglycaemia
Post op care for insulinoma
Monitor BG
Complications - transient hyperglycaemia
- persistent hypoglycaemia
- pancreatitis
Prognosis of 785 days, over 1000 days of has medical management following relapse
Function of the adrenal glands
Adrenal cortex secretes aldosterone, cortisone, sex hormones
Adrenal medulla secretes noradrenaline and adrenaline
What diseases to adrenocortical tumours cause
Cushings - dogs
Conns syndrome - cat, hyperaldosteronism
Clinical signs of cushings
PUPD Polyphagia Panting Abdo enlargement Alopecia Muscle weakness Lethargy Weight gain
How do you diagnose cushings disease
Low dose dexamethasone suppression test
What is phaeochromocytoma
Tumour of adrenal medulla Excess production of cathecholamines Weakness and collapse Panting Tachycardia Muscle wastage Can cause intermittent hypertension
How are adrenal tumours diagnosed
Ultrasound
CTto show metastasis and involvement of vena cava
What is the pre operative surgical stabilisation for adrenal tumours
Cortical tumour - trilostane pre op
Pheaochromocytoma - phenoxybenzamine is an alpha-adrenergic blocker - give 2 weeks pre op
- propranolol if persistent tachycardia
Surgical considerations for adrenal cortical tumour
Delayed healing
Pulmonary thromboembolism
Surgical considerations for pheaochomocytoma
Surgical manipulation can cause surges in catecholamine release - hypertension, tachycardia, arrhythmias, cardiac arrest
Monitor anaesthetic carefully
Propranolol for tachycardia
Lidocaine for arrhythmias
Surgical approaches of adrenal tumours
Midline laparotomy to removal cabal thrombosis
Flank approach
Laparoscopy
Risk of haemorrhage so have donor blood available
Post op care of adrenal tumours
Adrenocortical tumours - hypocortisolism post op
Steroid supplementation - dexamethasone peri op, prednisolone post op
Mineralocorticoid supplementation - monitor electrolytes as can have decreased sodium and increased potassium. Fludrocortisone
Features of conns syndrome in cats
Adrenocortical syndrome Increased sodium and water retention Hypertension Hypokalaemia Episodic muscle weakness Collapse
What is the hepatic blood supply
Hepatic artery - 20% blood, 50% oxygen
Hepatic vein
Hepatic portal vein - 80% blood, 50% oxygen
What is the function of the liver
Synthesis and clearance of albumin Metabolises glucose Production and activation of clotting factors Clearance of toxins Lipid metabolism Reticuloendothelial function Gastrointestinal function Storage of vitamins, fats, glycogen, copper
Symptoms of hepatic insufficiency
Hypoproteinaemia
Hypoglycaemia
Coagulopathy
Hepatic encephalopathy
Assessment of the liver
Clotting times APTT and PT
Liver, bile and gall bladder samples for culture to determine if antibiotics peri op are necessary - normal for bacteria to be in liver - amoxycillin
How to do liver samples
Ultrasound guided FNA or tru cut
Surgical biopsies are more accurate and safer
What are the indications for liver lobectomy
Biopsy
Mass removal - benign or malignant
Abscess
Liver lobe torsion
Features of a liver lobectomy
Partial or complete
Can remove up to 70% liver
Blood type as risk of haemorrhage - DEA 1.1 dogs, AB cats
Indications for biliary tract sx
Extra hepatic biliary tract obstruction - cholelithiasis, gall bladder mucocele, pancreatitis, neoplasia
Biliary tract rupture and bile peritonitis
Clinical signs of a problem with biliary tract
Non specific Lethargy Anorexia V+ Abdo pain Icterus Hypovolaemic shock in severe obstruction or bile peritonitis
What will haem and bio tell you if there’s a problem with the biliary tract
Decreased albumin
Increased bilirubin, cholesterol, ALP, ALT
Decrease vit k - 3 doses vit k at 0.5-1.5mg/kg sx
Coagulation abnormalities - fresh frozen plasma in emergencies 10ml/kg
Causes of bile peritonitis
Disease vs trauma
Therefore sterile or septic
Manage the peritonitis and treat the underlying cause
Surgical considerations for bile tract problems
Cholecystectomy
Cholecystoenterostomy
Better to preserve common bile duct rather than gall bladder
What is the outcome of extrahepatic biliary surgery
Often systemically unwell
Significant mortality
Poor prognosis in cats for neoplasia compared to inflammatory conditions
Post op care for extra hepatic biliary surgery
Intensive nursing Analgesia Monitor - usual paramenters, Bp, leakage of bile, signs of haemorrhage Haem and biochem Antibiotics only if infection present Monitor for sepsis or SIRS
What is a congentital portosystemic shunt
Vessel connecting the causal vena cava and hepatic portal vein
Can be extraheptatic - yorkies, westies
Can be intrahepatic - labradors, Irish wolf hounds
Clinical signs of Portosystemic shunt
Failure to gain weight Small Neuro signs - hepatic encephalopathy Urinary tract signs Gastrointestinal signs Drug intolerance
What does haematology and biochem show for portosystemic shunts
Microcytosis Anaemia Increased clotting times Decreased urea, albumin, cholesterol, hypoglycaemia Increased ALP and ALT Decreased USG
How do you test the liver function
Ammonia tolerance - ammonia converted to urea in liver. Very labile. Abnormal in most portosystemic shunts
Dynamic bile acids - 100% sensitive
How do you diagnose portosystemic shunt using imaging
Ultrasound
Portovenography - fluoroscopy provides info on shunt configuration, confirms shunt and gives info on intrahepatic vasculature