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
How do you medically manage a portosystemic shunt
Treat the clinical signs Manage hepatic encephalopathy Restricted protein diet Lactulose Antibiotics Seizure medication Manage for 2-3 weeks before sx
What are the goals of portosystemic shunt sx
Attenuate shunt - complete of partial ligation or use a gradual attenuation device
Restore normal portal blood flow
Resolve hepatic insufficiency and clinical signs
How is portovenography done
Catheter into jejunal vessel during surgery
Inject with contrast under fluoroscopy guidance
Surgical complications of portosystemic shunt
Portal hypertension Haemorrhage Neuro complications Hypoglycaemia Mortality 10% Complications greater if intrahepatic shunt Better outcome if complete attenuation
What history do you need to know for an orthopaedic exam
Medication
Duration of lameness
Onset
Is it static, progressive, deteriorating, improving
Is the lameness continuous or intermittent
Alters with exercise or rest
Altered by the ground surface
Which limbs does the owner perceive to be the problem
Is the animal a working or pet dog
Any concurrent problems
What does a lame animals gait look like
Head bobs down on good leg Shortened stride of good leg Scuffed nails Stifle pain limb is circumducted Hip pain - spinal scoliosis. Lateral sway or bunny hopping
What does ataxia mean
Pelvic limb in coordination
What does paraplegia mean
Neurological deficits and no motor function
What does paraperesis mean
Neurological deficits but motor function is present
How will a lame animal stand
Paw of limb taking the most weight is flatter and will be difficult to lift
Inward or outward pointing of the paw
Weight may be shifted onto thoracic limbs
Scoliosis of spine
Frequent sitting - pelvic lameness
Frequent lying down - thoracic limb lameness
How should you perform a physical exam for an orthopaedic patient
Examine the animal standing fully
Exam in lateral position working from the toes of each limb upwards
How should you examine joints
SPIRM Swelling Pain Instability Range of motion Manipulation
How do you examine limbs
SAP
Swelling
muscle Atrophy
Pain
What are the specific tests for a stifle
Cranial draw
Tibial thrust
Patella luxation
What are the tests for the hip
Ortolani test
What equipment is needed for an arthrocentesis
Spinal needle 5ml syringe Clippers Prep Sterile gloves Microscope slides EDTA tube Culture bottle
When do dogs usually show signs of elbow dyslpasia
From 5 months of age and before 2 years
What radiographs should be taken when elbow dysplasia is suspected
Craniocaudal
Mediolateral
Flexed lateral
What is an ununited anconeal process
Anconeal process does not fuse
Elbow stability compromised
Osteoarthritis forms
Radius is longer than ulnar creating a shear which separates the anconeal process from the ulnar as it rubs against the humeral trochlear
What is short radius syndrome
Short radius compared to ulnar
Incongruity of joint surfaces
Weight bearing on the medial aspect of the joint
Causes cartilage wear and fragmentation of the medial coronoid process and cartilage wear on medial humeral condyle
What is osteochondritis dissecans
Affects medial humeral condyle
Thicken flap of cartilage on humeral trochlea overlying a deep subchondral bone defect
Fragmented medial coronoid process
Most common pathology of elbow dysplasia
Craniolateral aspesct of medial coronoid
Appear dead and yellow in appearance compare to red well vascularised bone of the rest of the joint
What is arthroscopic debridement
Used to treat elbow dysplasia
Remove fragments via arthroscopy
The underlying subchondral bone is then treated with abrasion arthroplasty or micro fracture to encourage fibrocartilagenous repair
Joint flushed with sterile saline
What is abrasion arthroplasty
Hand burr or power shaver burr is spun to remove subchondral bone over the ware a of the lesion
Bleeding needs to be observed diffusely from the lesion bed
Lavage joint to remove debris
What is microfracture technique
Micro pick inserted into joint and press tip against subchondral bone surface
Tap handle once or twice
Apply diffusely across diseased area and check for resulting bleeding
Lavage to remove debris
What is a long bone osteotomy
Transfers weight bearing from medial aspect of the humerus to the lateral
Specific SHO plate used
Complications include humeral fracture, implant breakage
What are the indications for arthroscopy
Exploration of joints for discharge agnostics through observation, biopsy and culture
Removal of loose bodies
Microfracture and abrasion arthroplasty can be performed to treat osteoarthritis
Joint debridement and lavage
Arthroscopic assisted joint stabilisation or fracture repair
What are the advantages of arthroscopy
Decreased morbidity Rapid recovery Less complications Improved outcomes Decreased surgery, anaesthesia and hospitalisation times
Disadvantages of arthroscopy
High level of skill needed
Equipment is expensive
Expensive for client
What equipment is needed for arthroscopy
Arthroscope Camera mount Light post Cannula Irrigation Egress system - usually a needle in the joint Instrument cannulas Hand or power tools Electrocautery Patient prep Waterproof drapes
What are the causes of cruciate ligament disease
Traumatic due to a fall or stuck down rabbit hole
Degenerative is most common
Inflammation - rheumatoid arthritis
How do you diagnose cruciate disease
Mediolateral and craniocaudal views of both stifles
What is the first line of treatment for cruciate disease
Lead walk for 6 to 8 weeks
What is the aim of cruciate surgery
Confirm diagnosis by arthrotomy
Debride the ruptured ligament
Check and remove torn pieces of menisci
Stabilise the stifle joint
What does TPLO stand for
Tibial plateau levelling osteotomy
Decrease tibial plateau angle to 7 degrees from 24
Post op care for cruciate ligament surgery
Lead walk for 6 weeks Cage rest Physio Hydrotherapy Gradual return to exercise after 6wk post op X-rays
What types of surgery is there to correct cruciate ligament rupture
Lateral suture - extra articular stabilisation
Tibial plateau levelling osteotomy
TPLO using LCP plate
Cranial closing wedge ostectomy
Features of meniscal injuries
Medial usually more damaged
Subsequent to cranial cruciate ligament disease
Features of hip dysplasia
Presents 4-5months age
Laxity develops in joint capsule
Size of dog, rate of growth, diet and exercise
Thickening of joint capsule from inflammation
Erosion of acetabulum
Femoral head flattens
May see luxation
Clinical signs of hip dysplasia
Bunny hopping Difficulty rising Pelvic limb lameness or stiffness Exercise intolerance Clunking of hips Lateral swaying of spine Muscle atrophy of glutes
Conservative management of hip dysplasia
First line of treatment Most dogs should become sound by 15months old Lead walks Hydrotherapy Control food intake to slow growth NSAIDs
What is juvenile pubic symphysiodesis
Simple inexpensive procedure
Can be done when neutering
Fusion of pubic symphysis by electrocautery
Preventative measure
Less growth of ventral pelvis resulting in bilateral acetabular ventroversion allowing for increased femoral head coverage
What is triple pelvic osteotomy
Preventative measure
Increases dorsal coverage of the femoral head
Corrects subluxation
Restores hips weight bearing surface area
4-8months of age
Painful hips with no osteoarthritis
Pelvis cut in 3 places to free acetabulum
Acetabulum rotated 20 degrees
What is a femoral head and neck excision
Femoral head and neck removed
Fibrous pseudoarthritis form
Salvage procedure
Post op care of femoral head and neck excision
Rapid return to exercise key to prevent muscle wastage
Physio 2 days post op
What is a total hip replacement
New femoral head and acetabulum Chronically painful and arthritic hips No concurrent problems Conservative tx no longer effective Luxation pre op increases risk of luxation post op leave 6 weeks between contralateral hips
Cemented or non cemented systems in place
Complications of total hip replacement
Luxation Osteomyelitis Aseptic loosening Femoral fractures Implant failure Subsidence Sciatic neuropraxia Cement granuloma Pulmonary embolism
Post op care of total hip replacement
Lead walks for 6 weeks
Physio
Avoid slippery floors and jumping or playing
Gradual return to exercise after 6 week check
What are the clinical effects of opioids
Analgesia
Sedation in unhealthy or young
Dysphoria if too high a dose given
Cough suppression
Bradycardia due to stimulation of vagal tone - fentanyl. Atropine to correct
Respiratory depression by Mu receptor - fentanyl but unlikely in awake animals
Vomiting - morphine
Reduced gut motility and GI sphincter closure
Pupillary constriction
Can cross placenta and cause resp depression in neonatal - naloxone under tongue to manage
What receptor does butorphanol bind to
Kappa
Name some full Mu agonists
Methadone
Morphine
Fentanyl
Name a partial Mu agonist
Buprenorphine
Name an opioid antagonist
Naloxone
Blocks Mu receptors but does not provoke a biological response
What does potency mean
Concentration of a drug required to elicit half the maximum biological response of the agonist
Buprenorphine is the most potent
What does efficacy mean
Maximum possible biological effect a drug can achieve following binding to the receptor. Maximum possible analgesia that can be achieved
Morphine, fentanyl and methadone are most efficacious
Surgical considerations of nasopharyngeal atresia/ stenosis
Acquired or congenital
Sneezing, stertorous, URT obstruction
Diagnosis - rhinoscopy, CR, MRI
Open sx and resection of stenotic area through soft palate using endoscopy
Endoscopy guided stent placement works really well but is expensive
Duration of opioids
Fentanyl- 10 to 15 minutes. Given as CRI intraoperatively Butorphanol - 90 mins Methadone - 3-4 hours Buprenorphine - 6 hours Recuvyra - 96 hours
Why use opioids as a pre med
Increase sedation of alpha 2 agonists, acepromazine or benzodiazepines
Lower doses of sedative agent to be used
Reduced cardiovascular and respiratory effects
Preventative analgesia in healthy animals
How does methadone work as an analgesic
NMDA receptor antagonist so blocks up regulation of pain pathway
What opioids should be used intraoperatively
Methadone can be given as a bolus
Fentanyl cri to decrease volatile agent
May need IPPV
Stop cri 15 mins before end of surgery to ensure spontaneous respiration
Post operative administration of opioids
IV preferable
Pain score first
What doses of opioids should be given
Bup 20microg/kg
Methadone 0.3-0.5mg/kg
Morphine cri 0.2-0.25mg/kg/hr diluted
Fentanyl cri 5microg/kg/hr
Features of opioid CRIs
Constant plasma conc of the drug
Avoids peaks and troughs pain relief
Given via syringe driver
Label syringe with drug, dose, patient name, drug concentration
Give loading dose to ensure patient is comfy
Keep in separate bags
Features of opioid epidural
Morphine and bupivicaine
12-18hours
Do not need to adjust the amount of opioid given systemically if epidural also given but usually means a lower dose needs to be given
What drug should be given for chronic pain
NSAIDs
What are the potential side effects of NSAIDs
Vomiting
Diarrhoea
Gastric ulcers
Reduced renal blood flow from dehydration or fluid loss
Elevation of liver enzymes
Prolong blood clotting depending on COX1:COX2 selectivity
When are NSAIDs contraindicated
If hypertensive or dehydrated
If on corticosteroids
History of ulceration
Reduced renal function should be monitored as blockage of vasodilator prostaglandins may decrease the GFR in a GA
Liver disease - reduce dose
Cardiac disease
Hypoproteinaemia- NSAIDs protein bound so will increase free fraction and elevate side effect risk
What should you monitor following nsaid therapy and how often
Body systems where effects are most likely - GI, renal, liver, cardiovascular
Underlying disease conditions or concurrent disease
Problems will occur 14-30days but depends on animal.
Educate owner to recognise nsaid toxicity early and know the side effects
Assessment of NSAID efficacy
7-10days after starting therapy
Then 1 to 2 monthly periods
Owner keep diary about animals demeanour and activity level to determine QoL
If not tolerated or efficacious then change the nsaid used or give adjunctive therapy to increase analgesia
How can the GI system be monitored when on nsaid therapy
Has owner seen vomiting o diarrhoea, nausea or inappetance
Examine for signs of GI pain
Monitor body weight, PCV, TS
How do you monitor the renal system when on nsaid therapy
Urine sample
Any changes in drinking
Monitor plasma urea, creatinine, Bp
Monitor potassium is on pot supplements
How to monitor the hepatic system if on nsaid therapy
Any signs of lethargy
Monitors liver enzyme levels
Monitor serum bile acid conc if has pre existing liver dx to see if there’s changes in liver function
How to monitor cardiovascular system when on nsaid therapy
Ask about exercise tolerance
Monitor Bp
Monitor platelet count and function if going into sx
Mechanism of action of local anaesthetic agents
Block conduction of action potentials in nerves by preventing depolarisation
Decrease sensory input to spinal cord and brain
Sodium ion channels blocked
Reversible and not asssociated with loss of consciousness
Physio chemical characteristics of local anaesthetic drugs
Amide linkage - stable and can withstand heat sterilisation and pH changes
Metabolised in the liver
Lidocaine, bupivicaine, mepivicaine
What determines the potency of a local anaesthetic
Lipid solubility. Higher the lipid/water partition coefficient the more potent the drug
What determines the duration of effect of local anaesthetic
Protein binding. Highly bound drugs stay in the lipoprotein of nerve membranes longer
What effects the speed of onset of local anaesthetic
pKa determines the ratio of ionised to unionised drug
The lower the pKa, the more unionised base is present
Only unionised drugs can enter nerve membranes so the lower pKa the faster the onset
Features of lidocaine
Relative potency 2 Relative lipid solubility 3.6 pKa 7.7 Protein binding % 65 Onset fast 90-200mins action
Features of bupivicaine
Relative potency 8 Relative lipid solubility 30 pKa 8.1 Protein binding % 95 Onset medium 180-600 mins action
Why are myelinated nerve fibres more resistant to local anaesthetic
Local anaesthetic must prevent depolarisation in 3 to 4 nodes of ranvier
Internodal distance increases with diameter so need higher conc of local anaesthetic
Motor nerves less sensitive than sensory nerves
Wh are unmyelinated fibres more susceptible to local anaesthetic
Smaller length of the nerve fibre membrane must be blocked
Advantageous as a concurrent motor nerve block is usually undesirable
Sensory fibres blocked first - lower conc of drug needed
Characteristics of lidocaine
Stable in solution Unlicensed Short duration and onset Wide safety margin Addition of adrenaline prolongs duration
Characteristics of mepivicaine
Less toxic than lidocaine
Good for equine lameness diagnosis
Medium duration of action
Characteristics of bupivicaine
Stable Slow onset and long duration 4 times more potent than lidocaine Good motor and sensory separation Do not give IV
How can systemic toxicity of local anaesthetics occur
Vascular sites cause rapid absorption so reduce dose if going into area with good blood supply
Drug dependent
Speed of injection when given IV
Adrenaline causes vasoconstriction causing slow absorption
What effects do local anaesthetics have on the cardiovascular system
Slowing of conduction of myocardium Myocardial depression Peripheral vasodilation Hypotension Bradycardia Cardiac arrest
If adrenaline added - tachycardia and hypertension
What are the effects of local anaesthetics on the central nervous system
Seizures
Convulsions
CNS depression
Coma
How do you reduce the risk of toxicity following administration of a local anaesthetic
Small needle
Calculate the safe maximal dose depending on body weight
Draw up drug using appropriate sized syringe
Dilute with NaCl
Draw back and give slowly
Why apply local anaesthetic to mucous membranes
Produces analgesia within 5 mins
Lidocaine
Ocular exam, intubation, nasogastric tube placement
EMLA cream takes nearly an hour to work and must be applied thickly
What is infiltration analgesia
Local anaesthetic injected into skin at the edge of the previous weal
Only one needle prick felt
Used to close wounds, remove small growths and take biopsies
Using local anaesthetic for thoracotomy
First dose under GA Q8hrs Bupivicaine 1mg/kg in saline Give each side Stings so can give some lidocaine first
Anatomy of the eye
Ciliary body and iris rich in vessels and pigments
Limbus has stem cells that allows the cornea to heal
Optic nerve goes into optic disc
Lens behind cornea
Fundus at the back
What usually causes eye problems
Secondary to poor conformation of the eye
What are bulging eyes at risk from
Corneal ulceration
Serous discharge
Sclera visible which has more pigmentation to make tissue tougher and more resistant to irritation
Often blood vessels extend to cornea - sign of irritation
Corneal dryness
What should dogs eyes be tested for
Progressive retinal atrophy
As from 4years are night blind
From 8years can be day blind
Inherited condition
What equipment is needed for an ophthalmic exam
Pen torch Ophthalmoscope Fluorescein Schirmer tear test strips Tropicamide to dilate pupils Tonometer 20D condensing lens to look at retina and fundus
What are the different light filters for on a ophthalmoscope
White - direct illumination
Redfree light - differentiates vessels and pigments on the retina
Blue cobalt - to detect ulcers after fluorescein staining
When doing an eye exam what history do you need to know
Previous ocular conditions and response to treatments
Concurrent dx
Current ocular complaint - characterisation, onset, progression, duration
Question how well the animal can see
How is a distance ocular exam done
Body condition
Attitude
Face - symmetry, discharge
Eyelids - swelling, colour, size, palpebral fissure
Eyeballs - position in the orbit, size of the globe, direction, movements
Pupil - symmetry, size, shape, PLR
Use direct ophthalmoscope
How do you test vision
Menace response
Tracking response
Visual placing response
What are the clinical signs of neuro-ophthalmology
Strabismus - deviation of visual axis
Nystagmus
Aniscoria - different pupil sizes
Eyelid ptosis- drooping
What is the schirmer tear test
Tests for dryness
Tests the quantity of tears produced
Normal 15-25mm in a minute
What must be done before any diagnostic drops are used
Corneoconjunctival culture
How do you test for the quality of the tears
Use fluorescein and blue filter
Maintain lids open and measure time for dark spots and lines to appear after last blink
Normal 20s
Quicker they appear the poorer the quality
Difficult to perform
How do you perform an adnexa and anterior segment exam
Close exam with ophthalmoscope
To examine cornea, conjunctiva, eyelids and anterior segment
Use white light
What can you use fluorescein for
Corneal ulceration detection
Permeability of the nasolacrymal duct system
Tear break up time - tear quality test
What is the normal intraocular pressure measurement
10-20mmHg
How do you examine the lens, vitreous and fundus of the eye
Tropicamide
Wait 30 mins
How do you examine the posterior segment of the eye after pupil dilation
Monocular indirect ophthalmoscope to view fundus
Direct ophthalmoscope to visualise lesions in detail
How do you increase the concentration of eye drops and what order do you give multiple tx
Increase the frequency not the number of drops
Give in order of viscosity- solution, suspension, lubricant
Features of bandage contact lenses
Shields migrating epithelial cells
Complications not common
What topical antibiotics can be used on the eye
1st intention - fucidic acid, chloramphenicol
2nd intention - gentamycin
3rd intention - ofloxacin acts against pseudomonas aeruginosa
Topical corticosteroids that can be used on the eye
Reduce inflammation
Prednisolone 1%
Dexamethasone 0.1%
Topical NSAIDs that can be used on the eye
Multimodal therapy with steroids to reduce frequency of admin
Ketorolac
Bromfenac
Immunosuppressant drugs that can be used on the eye
Cyclosporine
Tacrolimus
To treat keratoconjunctivitis
What antiproteolytic therapy can be used in case of ulcers
Serum
EDTA
Administer every hour if deep ulcer
How do you treat glaucoma
Reduce the production and increase the drainage of aqueous humor in the eye
Carbonic anhydrase inhibitors
Prostaglandin analogues
What can be used to treat intraocular inflammation
Atropine - mydriatic agent
What are common eye complaints in consultation
Red eye Cloudy Blind Purulent Painful
What can cause an eye to look red
Inflammation - can be urgent
Haemorrhage - can be urgent
Vasodilation - can be urgent
Neovascularisation associated with corneal ulnar - urgent
Need to see that day if possible
What is exophthalmos
Abnormal protrusion of the eye ball
E.g. Orbital foreign body
What is globe proposes
Eye has come out of the socket
Try to save
Tell owner to keep moist and come quickly
Suture eyelid over eyeball until swelling goes down
What is enophthalmos
Recession of the globe into the orbit
Horner syndrome
What is a macropalpebral fissure
Eyelids not big enough to cover whole eye
Lubricant and sx
What is ectropion
Exposed conjunctiva
Dryness and impaired eyelid function
What is entropion
Eyelid is inverted
Can be primary or secondary
Sx to treat
What does a normal conjunctiva look like
Pale in cats
Light pink in dogs
What does blue cornea mean
Lesion of the superficial layer of the cornea
Causes water uptake in the cornea - corneal oedema
Urgent
What does a red cornea mean
Corneal neovascularisation
Sign of a superficial ulcer
Fine vessels with no branching is a sign of a deep corneal lesion
What does a white cornea mean
Corneal scar
Lipid keratopathy - lipid deposits associated with hyperlipidemia
Stages of a corneal ulcer
Epithelial layer and involvement of stroma to give melting appearance
Deep ulcer is very vascular and has purulent discharge
Corneal perforation has fibrin surrounding it
What are the clinical signs of cataract
Lens opacity
What are the signs of ocular pain
Increased blinking Rubbing at eye Redness Photophobia Increase lacrimation
How do you treat third gland prolapse - cherry eye
Sx Buster collar 1st line antibiotics Lubrication NSAIDs
What is keratoconjunctivitis sicca
Immune mediated Dry eye - no tear production Ocular pain Mucoid discharge Inflammation Decreased vision and progressive corneal disease Use schirmer tear test
What is the treatment for keratoconjunctivitis sicca
Lubrication
Immunomodulating agent
Broad spectrum antibiotic
Topical anti inflammatory
How do you treat an infected ulcer
Antiobiotics hourly Serum hourly Lubrication NSAIDs Reconstructive corneal sx
History taking for animal presenting with a mass
When first noticed
Has it grown
Changed appearance
Any other masses visible
What tests can be done to see what a mass is
FNA submit for cytology
Biopsy of FNA inconclusive - tru cut, incisional, excisional - bear in mind future sx
Biopsy can cause metastasis of mast cell tumours
Tumour staging
TNM
How do you stage the actual tumour
Size Growth rate Location Local invasion Histological type and grade
How do you tell if a tumour has spread to lymph nodes
Assess draining nodes
Palpation
FNA
Surgical biopsy
How do you tell if a tumour has metastasised
Lung - inflated radiographs and CT
Look in the abdomen, brain, skin etc
What are the considerations for tumour excision
Tumour type and grade
Tumour stage
Size and location
What surgery can be performed on tumours
Incisional biopsy Debulking Marginal excision Wide excision Radical excision e.g. Maxillaectomy
Why do you need histopathology after tumour removal
Look at cells at the edge of the sample to see if tumour has been removed
Fill out forms comprehensively
Essential
Ink margins
Best way to close after tumour removal
Keep simple
Avoid tension
Place drain
Post op chemo or radiography
Considerations for drain placement after tumour removal
Entry point as close to surgical incision as the tract is now part of the wound
If sx needs to be devises the tract also needs to be removed as can now contain cancer cells
What are the reasons for wound breakdown post sx removal of a tumour
Patient factors rare Concurrent disease Nutrition Chemotherapy Radiotherapy Steroids Neoplasia Tension Tissue handling Motion Sutures - wrong technique Infection Patient interference
What areas are a problem for tumour removal
Distal limb
Axilla
Bony prominence
Consider axial flaps
How do you treat wound breakdown post sx
Do not resuture
Heal by 2nd intention
How do you prevent seroma formation
Prevent dead space by placing drains Halsteads principles - treat tissue with respect Rest Leave alone Pressure bandage Provide further drainage
How do you treat infection after a tumour has been removed
Drainage
Heal by 2nd intention
Antibiotics after culture and sensitivity
Wound exploration if necessary
Why might there be tumour recurrence
Dirty margins
First cut is the best as don’t want revision sx
May already be metastasis
What types of sub dermal plexus flaps are there
Advancement flaps
Rotational flaps
Transposition flaps
Skin fold flaps
What are the principles of sub dermal plexus flaps
Wider base than body Limit size Avoid narrowing Undermine panniculus Atraumatic surgical technique Take from area with ample skin Avoid excessive stress or motion at donor site
What is an advancement skin flap
Flap parallel to line of least tension
Stretched into defect
Loose skin adjacent to wound
Prone to dehiscence
What is a rotational skin flap
Skin rotates to close triangular defect
Radius of rotation is the length of the wound
What is a transposition flap
Flap parallel to tension
Rotated into the defect
Maximise width of base
Length equal to pivot arc
What is a skin fold flap
Axillary or inguinal skin folds
Versatile and large
Sternal and groin wounds
What are the complications of skin flaps
Seroma
Dehiscence due to too much tension
Flap necrosis from technical error or trauma
What are axial pattern flaps
Involve a direct cutaneous artery
Superficial landmarks
Flap dimensions depend on conformation
What are the indications for axial pattern flaps
Large wounds on flank or proximal limb Reconstruction post tumour excision Chronic non healing wound Avascular wound bed Need to cover exposed bone Provision of muscle bulk
What are the advantages of axial pattern flaps
Durable full thickness skin Blood supply Normal hair growth Morbidity less likely Can be larger than subdermal plexus flaps
What are the four major axial pattern flaps
Caudal superficial epigastric
Thoracodorsal
Omocervical
Deep circumflex iliac
Features of a thoracodorsal axial pattern flap
Thoracodorsal artery cutaneous branch
Shoulder, forelimb, elbow, axilla, thorax, carpus
Large, durable and robust
Features of a caudal superficial epigastric axial pattern flap
External pudendal and caudal superficial epigastric artery
Caudal trunk, inguinal, perineum, pelvic limb to hock
Mammary tissue remains functional
What are the post op care considerations for skin flap sx
Bandage to remove dead space and immobilisation of limb
Drain care
Analgesia
Antibiotics if needed
What are the complications of axial pattern skin flaps
Necrosis of flap Seroma Failure to adhere Dehiscence Infection
18mnth m(n) dlh cat Missing 24hrs Large wound in inguinal region Recumbent but responsive How would you approach this case
Major body system assessment Place catheter Pain relief no NSAIDs IVFT if needed Full body exam Minimum database Wound classified as dirty
How would you manage a day old dirty wound
Ga Clip area around wound Lavage with saline Sx debridement Swab Broad spectrum antibiotics Keep patient warm
After cleaning a dirty inguinal wound what is the next step
Wet to dry dressing to provide debridement
Nappy style bandage
Tie over dressing
Urinary catheter
Feeding tube
Long stay catheter in saphenous vein or jugular line
Once a wound has been suitably debrided what dressing would you use
Intrasite - osmotic effect causing gentle debridement
Alleyvn as very absorbable and is semi permeable so allows O2
Will give intrasite in and stop drying out
7yr m(n) cross breed Wound over left hock Possible bite Previous partial tarsus arthrodesis How would you manage this wound
Clip Lavage Swab Surgical debridement Wet to dry dressing Intrasite or homey with alleyvn Antibiotics Remove bone plate and drill holes in bone to encourage granulation tissue over exposed bone
What are the indications for a free skin graft
Wounds on distal limb
Primary closure not possible
Healthy granulated wound
What are the contraindications for a free skin graft
Wounds on head and trunk as rely on blood supply from local area so can’t have any movement, can immobilise limbs
Infection
Incomplete granulation bed
Debris
How should you care for skin grafts
Aseptic technique Immobilisation of graft Prevention of fluid accumulation Sedation or ga for dressing changes as don't want movement Keep bandages on for 2-3 days
Pros and cons of skin grafts
Cover distal limb deficits Labour intensive and time consuming Grafts take time to be fully functional Variable cosmetic and functional outcome Other reconstruction techniques preferred when possible
What are the main concerns of dog bite wounds
Contaminated
Superficial skin wound but crushing injury to underlying muscle
Puncture wounds to deeper structures
How should dog bite wounds be managed
Ga Clip fur Lavage Explore Swab Antibiotics
What are your concerns for a dog bite to the neck
Damage to jug vein, carotid artery, recurrent laryngeal nerve, trachea which could cause emphysema, crepitus or pneumonia
Always always explore
What are the goals of wound management
Prevent further conta,inaction Remove debris and contamination Debride dead and dying tissue Promote a viable vascular bed Patient considerations Select appropriate method of closure
What is the initial care for an equine fracture
Do not move horse until need for stabilisation is known
Sedate
Treat wound - clip, clean, sterile bandage
Stabilise fracture
Meds
What clinical signs would you see with a suspected equine fracture
Sweating Shock Pain Lameness Palpable instability Crepitus Soft tissue swelling
What are the goals of fracture stabilisation
Stabilise fracture
Reduce discomfort and distress
Minimise further trauma to bone, soft tissue and vasculature
Prevent further contamination if open wound
Include joint above and below fracture and splint to way above fracture line
What are the options for a stabilising bandage
Robert jones
Splint using anything available
Cast
What medication would you give a horse with a fracture
Antimicrobials
Analgesia - NSAIDs and opioids
Tetanus toxoid
IVFT to treat shock and haemorrhage
What do you need to have ready for when an equine fracture comes in
Drugs Bandage material Splints Cast material Catheter Fluids Turn radiography equipment on
What surgical equipment do you need for an equine fracture repair
Drapes General kit Fracture kit - 4.5mm set and screws - 5.5mm set and screws - locking plate and screws Drill Intraoperative imaging and gowns Arthroscopy equipment Bone reduction forceps Plate bender Hand held retractors Self retaining retractors Clippers and prep Fluids Bandage cart Cast material Suture material Ropes Support stands for legs
Patient prep for equine surgery
Cover feet and tail
Clip hair 10-15cm radius from surgical incision
Clean skin
Disinfect skin
What are the assisted recovery options post equine surgery
Head and tail rope
Sling recovery
Pool recovery
What is the post op care for equine fractures
Analgesia and antimicrobials
Monitor vitals - HR should be less than 40
Monitor comfort, appetite, faecal output, catheter
Check cast for breakage, discharge, heat
Frog support on opposite limb
Rest 4 months
What are the complications of equine orthopaedic surgery
Infection
Unstable fixation - pain and longer healing
Laminitis common in other foot
Before an equine arthroscopy what should be done before
Radiographs
Catheter
Meds
Prepare theatre
What are the components of arthroscopic equipment
Arthroscope Video camera Tv screen Light source and light cable Fluid irrigation system Motorised equipment
What surgical instruments are needed in an arthroscopy
Egress cannula Forceps Probes Osteotome and elevators Cutting instruments Curettes
What is the post op care for an equine arthroscopy
Monitor lameness - stifle usually sore for 24hrs. Other joints should be sound walking Temperature Bandage Appetite Faecal output
What are equine emergency surgeries
Colic
Lacerations
Dystocia
What history do you need to know for colic
How long How severe Response to meds Had colic before Had sx before Had a foal Age Geography Breed
Clinical exam for equine colic
Abdo discomfort HR Temp of ears and feet Pulse quality Mm Rectal temp Resp rate Abdo distension GI sounds Rectal exam Ultrasound abdo Abdominocentesis
What do you need to have ready for when a colic comes in
Sedation Buscopan NSAIDs Stethoscope Clippers and prep Catheter NG tube and bucket Rectal sleeve and lubricant Ultrasound machine
What are the two types of colic
True colic - gastrointestinal
False colic - urofenital tract, resp system
Preparation for colic surgery
Catheter Clip abdo Meds Pass NG tube Prep patient Prep theatre
What equipment do you need for colic surgery
Clippers Urinary catheter Prep Fluids CMC carboxymethylcellulose General set Drapes
What instruments do you need for small intestinal colic
Doyen clamps Penrose drains Separate drapes Suture material Fluids for lavage Staples for anostomosis Fresh clean table with new instruments to close
What instruments do you need for large intestinal colic
Colon tray Drapes Separate table as contaminated Hose with tap water for lavage Sterile fluids for lavage
How much care do colic patients need post op
If systemically healthy need minimal care
- pain meds and systemic antimicrobials
- gradual refeeding
Systemically compromised need intensive care
- endotoxemia
- ileau
- anostomosis not functional
Monitoring of colic patients post op
HR Pulse quality Mm Hydration - PCV/TP/USG GI sounds Defecation Check for nasogastric reflux - up to 5l/hr Comfort - laminitis and colic Appetite Temp Surgical wound Abdo bandage
What is the intensive care for a colic patient
Meds IVFT PE every 4-6 hours PCV/TP/USG every 4-6 hours Gradual refeeding Walking helps to kickstart GI system
What are the most common wounds for horses
Distal limb lacerations
60% of all wounds
Why are distal limb wounds in horses so challenging
Extensive crushing or avulsion of soft tissue
Exposure of bone
Vascular compromise
Severe contamination
Less skin to mobilise
More likely to dehisce
Increased exuberant granulation tissue
Decreased contraction and epithelialisation
May include many critical synovial and supporting structures which can result in permanent loss of use or death
How do you manage an equine wound
Cleansing
Exploration
Radiographs
Determine if synovial structures are involved
Debridement with lavage of synovial structures
Suture
Antimicrobials
How do you cleanse an equine wound
Clip hair around wound but protect the wound whilst doing so
Irrigation - 18g needle and 60cc syringe
- saline or tap water and an antiseptic (povodine iodine or chlorhexidine)
Prep skin
Why and how do you explore an equine wound
Determine extent of wound, if there’s a FB and if synovial structures are involved
Use a probe
Radiographs for Fb and to check for fracture, look for air around synovial structures
Contrast studies for synovial structures
Why is it important to check for involvement of synovial structures in an equine wound
Less than 6-8hours before they are contaminated
If not recognised chronic injuries massively reduce prognosis - prognosis is good if treated aggressively from the start
Know the anatomy of the joint pouches and sites of injection
What do you need to have ready for when an equine wound comes in
Clippers and prep Fluids for lavage Probe Gloves Catheter Radiography equipment turned on Sedation Antimicrobials Pain med Bandage cart
What equipment do you need to close an equine wound
Clippers and prep Fluids for lavage Standard kit Arthroscopy equipment Bandage cart Drains
What is the post op care for equine wounds
Systemically healthy
Bandaging
Meds
Monitor usual parameters
What are the normal stages of equine labour
1 - relaxation cervix and uterine contractions
- restlessness, pacing, pawing, posture to urinate
2 - 10-15min up to 70min
- onset rupture chorioallantois and delivery of foal
3 - passing foetal membranes
At what point does equine labour become dystocia
Stage 2 longer than 30 mins
Likelihood of dead foal increases by 16% every 10mins
What history do you need to know for a mare with dystocia
Signalment Gestational age Pertinent medical history Time of stage 2 onset Has assistance already been attempted
What do you need to evaluate with a dystoic mare
Physical exam - pale mm and low HR Determine foetal orientation Determine the viability of the foal - always assume alive unless proven otherwise Ask if foal or mare is the priority Cost Distance to referral hospital How healthy is the mare
What are the methods for equine dystocia resolution
Assisted vaginal delivery
Controlled vaginal delivery
Csection
Fetotomy
Features of equine assisted vaginal delivery
Maintain hygiene Lubricate Manually reposition foal Sedation Clenbuterol to relax uterus Epidural anaesthesia
When is a fetotomy performed
Non viable foal
Cost
Need experience to do
Features of equine controlled vaginal delivery
GA with mechanical ventilation
Hind limbs elevated
15mins max
Simultaneously prep for c-section
Features of an equine c-section
Ventral midline laparotomy Localise uterine horn and exteriorise Hysterotomy Exteriorise foal Control haemorrhage Routine closure Should be 20mins max until foal extraction
Post op care for mare that had dystocia
Antimicrobials and NSAIDs Oxytocin every hour - if retained placenta for more than 6 hours then infuse 80IE over 30 mins Hydrotherapy vulva Stimulate GI system and adapt diet Uterine lavage
Why perform a terminal c-section
Mare with terminal illness - laminitis, cardiac failure, neuro
Full gestation and in parturition
Options for euthanasia- captive bolt, GA or sedation with local anaesthesia
If neonatal foal not breathing
Intranasal O2 8-10l/min
Mouth to nose
Intubate and ventilate
What should you do if a neonatal foal has bradycardia or no heartbeat
Should be 80-120bpm Thoracic compressions 100/min After 40secs IV adrenaline Antagonise medication used on mare Stop when heart rate is more than 60 Bp and spontaneously breathing more than 16/min
What are the complications of dystocia
Trauma of the reproductive tract - lacerations or rupture Retained placenta Delayed uterine involution Bladder prolapse Metritis Peritonitis Arterial haemorrhage Uterine prolapse Neuropraxia Pressure necrosis
What are the stages of orthopaedic healing
Post op 24-48 hours - pain, oedema, healing tissues
Regeneration day 5- 3 weeks - new collagen fibres forming. Still fragile so relative rest
Remodelling and bone healing 6 weeks to 1 year - consolidation, maturation (10wk to 1 yr), bone regeneration (bridging and callous forms) and remodelling
Treatment in post op stage of orthopaedic healing
Analgesia - need to know if sufficient or too much
Cryotherapy - 10 mins x3
Rest
Easy movement only - supported weight bearing
What is the treatment for the regeneration phase of orthopaedic patients
Controlled lead exercise
Passive and active ROM exercises
Can help reduce swelling
When considering non emergency orthopaedic surgery what can you do as prep beforehand
Weight loss especially if obese
Hydrotherapy but stop post op until sutures removed
Immediate post op care for joint surgery
Cryotherapy
If haemorrhage then pressure dressing for 12-24hrs
PROM to maintain normal ROM, blood and lymphatic circulation. Stimulates sensory awareness
Massage can reduce oedema
Pain management
Post op care for joint sx
Therapeutic exercises after a few days to encourage muscle strengthens and re-education
Weight bearing exercises and if not weight bearing then weight shifting exercises
Low impact initial exercises
Hydrotherapy
If in cast then PROM on adjacent joints
Hot therapy after 5 day inflammatory period can be done
If normal gait function not expected - sit to stand exercises to build glutes and prevent fibrosis and loss of motion
Luxation - Rehab as soon as sling removed. Weight bearing exercises limited. Don’t abduct or adduct limb
How to treat animals who have a total hip replacement
Lead walk v slowly
Keep patient calm and settled - sedate if needed
Clear signage so people know how to handle them
Anatomical types of fractures
Articular - joint
Physeal - growth plates
Condylar - long bone
Commonly seen fractures
Humeral condylar fractures - Spanials, check other limb
Maxillary or mandibular - cats. Tube feeds
Radial/ulnar - RTA, horse kick, dropped
Femoral - sciatic nerve damage. Lots of physio
Tibial/fibular - RTA/ trauma
Pelvic - assess bowel/bladder care, care with ,offing and ensure stable. Can be completely recumbent or still able to walk
Features of external fixations
Can be difficult to apply treatments
Can apply ice to parts of limb
PROM achievable with linear or ring fixators
May be reluctant to flex/extend limbs so active exercises useful
Work on extension of distal limb
Care for the pin tracts don’t excessively clean or cover too much and trap air
Ensure patient comfort
Common tendon injuries
Lacerations
Seen in conjunction with wound
Supraspinatus tendon calcification common with agility dogs
Rehabilitation for tendon injuries
PROM after 3 weeks rest
Limited exercise for 3-6 weeks
Tendon still not at full strength at 6 weeks
When rehabilitating any patient what do you need to consider
Client and you have the same goals Communication is key with clinician Have a plan Know how progress will be assessed How will you communicate progress with the client Do you have access to a physiotherapist
What are the primary goals of rehabilitation of the orthopaedic patient
Get patient weight bearing
Active range of movement
Muscle building
What are the effects of atropine if dosed wrong
Too low dose - more bradycardia
Too high dose - tachycardia - wait it out
