Week 4 - Perioperative evaluation, patient prep, and post-operative care

Question 1

PRE-OPERATIVE ASSESSMENT
• Consider it as ___-___ planning
• Provides a solid _____ for the surgical procedure
• Gives _______ physiologic data for the patient
• Facilities assessment of ______ and the ________ to the surgery

Answer 1

pre-surgical, foundation, baseline, disease, relevance

Question 2

PRE-OPERATIVE EVALUATION OF
THE PATIENT
• _____ communication and owner _____
• WITH _______!
• Thorough _____ [including medications/supplements]
• Physical ______
• ______ restriction [whenever possible]
• _______ data
• Determination of surgical ___ [____ status]
• Patient _______
• Pre-surgical ______

Answer 2

Client, consent, SIGNATURES, history, examination, Dietary, Laboratory, risk, ASA, Stabilization, medications

Question 3

CLIENT COMMUNICATION

• Extremely important
• Prior to surgery owner should be informed about?

Answer 3

• Diagnosis
• Prognosis
• Surgical options
• Non-surgical options
• Potential complications *
• Post-operative care
• Cost = low and high end of the bill

Question 4

HISTORY

• Regardless of the procedure, make sure you’re aware of previous _______ _____.
• Usually obtained from the _____ or _____.
• In an emergency, a _____ history is usually given [eventually a ______ history is obtained]
• ______ history vs. _____ history
• Should always include – ?

Answer 4

medical history, owner, caregiver, brief, thorough, General, Specific, signalment, diet, exercise, past medical problems/surgery, any recent treatment

Question 5

PRE-OPERATIVE EXAM [PE]
• Determines if the patient is ______ enough to safely undergo _______ and _____
• _______ evaluation of all body systems
• Evaluation of ___-______ physical status
• Patients general body _______ should be noted
• _____ condition, ______, and ______ status
• Ensure thorough _______ evaluation and ____ function assessment
• Rule out a heart _____ or abnormal ______
• +/- Full ____ and _____ examination
• Remember to check ____
• Looking for ______ or ______.

Answer 5

healthy, anesthesia, surgery, Systematic, pre-anesthetic, condition, Body, attitude, mental, cardiac, lung, murmur, arrythmia, neuro, ortho, kennel, diarrhea, vomiting

Question 6

DIETARY RESTRICTIONS
• _____
• Withhold food for ___-____ hours ____ to surgery [pending patient status]
• Continue to offer ____
• _______ Animals [ie: dogs, cats, swine]
• Fast ___-____ hours prior
• ______ [ie: cattle, sheep, goats]
• Fast ~___-___ hours prior
• _____ and _____ [includes mice, rats, guinea pigs, hamsters]
• High ______ rate
• ____ fasting prior
• ______ Animals [<8 weeks of age; <1 lb]
• _______ concerns –> leads to ?
• Do not ______ water
• Withhold food ___-___ hours prior to anesthetic event

Answer 6

NPO, 6 – 12, prior, water, Monogastric, 6-12, Ruminants, 12 – 24, Rodents, Rabbits, metabolic, No, Underage, Hypoglycemia, seizures, withhold, 1 – 2

Question 7

PRE-OPERATIVE BLOODWORK
• Depends on the animal’s physical status and the procedure being performed
• Elective or routine procedure
• Emergency
• Reduces risk and increases safety
• Provides a baseline for the patient
• Takes into account patient’s behavior
• Normal bloodwork è Proceed with surgery
• Abnormal bloodworkè Workup and/or treat prior to anesthesia vs. emergency surgery

Question 8

PRE-OPERATIVE BLOODWORK
• Ideally routine bloodwork completed before any procedure
• Patients undergoing elective procedure [~6 months – 4 years]
• Hematocrit [PCV]
• Total Protein [TP]
• +/- Limited biochemical and urine screening [BUN, Creatinine, USG]
• Mature adults [5 – 7 years]
• Complete blood count [CBC]
• Comprehensive serum biochemistry profile [Chemistry Panel]
• Urinalysis
• 8+ years
• Complete blood count [CBC]
• Comprehensive serum biochemistry profile [Chemistry Panel]
• Urinalysis
• Thyroid Panel [minimum T4]
• Additional Testing
• Coagulation function test, especially for patients with liver disease, maldigestion disorders,
NSAID usage, and breed predisposition

Question 9

BLOODWORK FOR
LARGE ANIMAL
• Indicated for horses based on age and systemic
status
• Horses younger than 4 years old and healthy
• Packed cell volume [PCV]
• Total Protein
• Horses greater than 4 years old and systemically ill
• Complete blood count [CBC]
• Chemistry Panel
• Electrolyte measurement for right-sided abomasal
disease of the dairy cow
• Urinalysis in the dairy cow to evaluate the presence
of ketosis
• Measurement of BUN [blood urea nitrogen] and
Creatinine, if urinary problems are suspected
• Analysis of peritoneal fluid prior to laparotomy for
horses with colic

Question 10

Important b/c we want to classify the patient prior to surgery so we know the likelihood of a patient having a cardiac emergency. We number it from 1-5.
If 5, make sure anesthesiologist is with you.
Higher the number, greater risk of anesthetic or surgical complications.

Question 11

PATIENT STABILIZATION
• Patients should be ______ as thoroughly as possible before surgery
• Correct fluid ____
• Stable dehydrated open ____ patient (make sure patient does not have skin infection)
• Correct ____-____ and ____ abnormalities
• Treat underlying ______

Answer 11

stabilized, deficits, pyometra, acid-base, electrolyte, infection

Question 12

PRE-OPERATIVE MEDICATIONS
• Maropitant [Cerenia] – 1mg/kg ___ minutes – ____ hour before pre-medications
• Reduces ______, especially if using _____
• May have __-_____ properties
• Potential ______ recovery from gas anesthesia and hasten
return to eating
• Pre-medication – Many different variations and combinations
• Dexmedetomidine/Butorphanol
• Midazolam
• Diazepam
• Hydromorphone = notorious for causing nausea and vomiting,
so make sure you have antiemetic prior to administering.
• Methadone
• Ketamine
• Pre-emptive analgesia
• NSAID [Carprofen, Meloxicam]
• Local Anesthetic [Lidocaine, Bupivacaine]
• Opioids
• +/- Antibiotics [ie: Cefazolin]

Answer 12

45, 1, vomiting, Hydromorphone, anti-inflammatory, smoother

Question 13

EXCRETIONS
• Allow patient to urinate and defecate prior to induction
• Abdominal Surgery
• Empty bladder
• Colonic Surgery
• +/- Enema
• Bladder Distention
• Could lead to a rough recovery

Question 14

REASONS TO DELAY SURGERY
• High Fever
• Rule out _____
• Recent _______ Signs [24 – 48 hours]
• Pyoderma = ?
• Infection
• Urinary Tract Infection [URI]
• CIRDC = ?
• Sick
• Uncontrolled ______
• Uncontrolled ______
• In heat = ?

Answer 14

stress, Gastrointestinal, skin infection, canine infectious respiratory disease complex aka kennel cough, Diabetic, Hyperthyroid, always try to reschedule it b/c there is an increased chance of complications b/c tissues are swollen and more friable.

Question 15

*****HALSTED’S SURGICAL PRINCIPALS
• Strict _____
• ________
• Preservation of _____ supply [accurate anatomical _______]
• _____ tissue handling and manipulation
• Avoid excess _____ on tissue during wound ____
• Accurate tissue _______ in wound closure
• Elimination of _____ space

Answer 15

asepsis, Hemostasis, blood, dissection, Gentle, tension, closure, apposition, dead

Question 16

Tips to reduce risk of surgical site infection

Answer 16

Question 17

WOUND/SURGICAL CLASSIFICATION

Answer 17

• Clean
• Clean-Contaminated
• Contaminated
• Dirty

Question 18

CLEAN WOUND/SURGERY
• Involving non-_______, non-_______, and non-______ surgical site
• _______, ____, and _______ tract not entered
• Examples ?

Answer 18

contaminated, traumatic, inflamed, Gastrointestinal, urinary, respiratory,
• Neuter/Ovariohysterectomy
• Arthrotomy for removal of a chip fracture of a carpal bone
• Elective orthopedic surgery
• Total hip replacement
• PDA

Question 19

CLEAN-CONTAMINATED WOUND/SURGERY
• Operative wounds/surgery in which the _______, _____, and _______ tract is entered, under ______ conditions without ____ contamination
• Examples ?

Answer 19

gastrointestinal, urinary, respiratory, controlled, unusual
• Abomasopexy [displaced abomasum in dairy cows]
• Enterotomy [foreign body removal] **not every foreign body surgery is clean contaminated
• Small Intestinal Resection
• Bronchoscopy

Question 20

CONTAMINATED
WOUND/SURGERY
• Surgery where gastrointestinal contents or infected urine spill into an open
cavity
• Examples:
• Cystotomy with spillage of infected urine
• Bile spillage during a Cholecystectomy
• Surgery where major break in aseptic technique occurred
• Open, fresh, accidental wounds
• Lacerations

Question 21

DIRTY WOUND/SURGERY
• Old traumatic wounds with purulent discharge
• Devitalized tissue
• Surgery where a hallow organ is perforated or fecal contamination occurs
• Gross spillage of contaminated body contents
• Examples:
• Septic peritonitis
• Rupture/perforated intestines, gallbladder, or pyometra
• Abscess

Question 22

SURGERY SITE INFECTIONS [SSI]
• Infection that occurs in the skin +/- ______ tissue at a surgical site within ____ days of the surgical procedure
• Endogenous _______ ____ are common culprits
• ___________ _____
• ___________ spp.
• _______ wound or incision site with ______

Answer 22

subcutaneous, 30, microbial flora, Staphylococcus aureus, Streptococci, Inflamed, discharge

Question 23

SURGICAL SITE PREP: CLIPPING HAIR
• Should take place in the ______ room
• ______/______ prep area
• Performed under ________
• Clip hair and _______ over propose surgical field
• Initial clipping should be done ____ the hair growth pattern
• Subsequent clipping should be ______ the pattern of hair
growth to obtain a ____ clip
• Use a number __ blade
• Avoid razor ____
• Express _______

Answer 23

preparation, Anesthesia, surgical, anesthesia, vacuum, with, against, closer, 40, burn, bladder

Question 24

Disinfectants and Antiseptic

Answer 24

Question 25

SURGICAL SITE PREP: SKIN PREP • Aseptic surgical site prep [location = OR] • Select appropriate antiseptic solution • ________ ___% scrub – most commonly used • ________-______ ___% scrub – _____ and some ______ procedures • Alcohol based ________ – follow manufacturer’s instructions • Aseptic preparation based on _____ time with antiseptic • Minimum ___-minute contact time! • Exception when using _____-based antiseptics • Remember – ___ minutes for PVI when using it as a _______

Answer 25

Chlorhexidine, 4, Povidone-iodine, 10, periocular, orthopedic, antiseptic, contact, 5, alcohol, 15, sporicidal

Question 26

SURGICAL SITE PREP: SKIN PREPARATION • Takes place in the OR • If skin is very dirty – perform an initial scrub • 3 additional scrubs performed • Common combination is chlorhexidine and alternating with alcohol • Scrub at incision site, near center, and move outwards in a circular fashion

Question 27

SKIN PREPARATION GOALS • Reduce resident skin flora to prevent infection • Achieve residual antiseptic activity • It is NOT possible to completely sterilize the skin

Question 28

PATIENT POSITIONING • Vital for effective surgical procedure • Positioning dependent on the procedure • Dorsal recumbency • Sternal recumbency • Lateral recumbency • Prep area • Heat source • +/- trough

Question 29

FLUID THERAPY • Intraoperative fluid therapy helps restore and maintain tissue fluid, as well as electrolyte homeostasis and central euvolemia • 10 – 15 mL/kg/hour of crystalloid fluids • Lower rate (5 mL/kg/hour) may be used for healthy patients undergoing less invasive elective procedures • Fluid losses • Large abdominal and thoracic incisions have much larger evaporative losses • Prewarming fluids

Question 30

DRAPING • Creates and maintains a sterile field around operative site • Occurs after patient has been positioned on OR table and skin has been prepped • Performed by a gowned and gloved surgical team member • Draping options: • 4 corner drape • Pre-made fenestrated drape • Making fenestrated drape

Question 31

DRAPING CONTINUED... • Orthopedic procedures on limbs • Free-draping technique • Limb is suspended using IV stand with foot enclosed in a clean latex glove • Vet wrap is used over the glove to help secure the foot with adhesive tape to the IV stand • Triangle of drapes are placed around base of limb

Question 32

DRAPING • Minor procedures [ie: lumpectomy[ • Small fenestrated drape is sufficient • Spay and neuter • Small fenestrated drape if sufficient • Tail amputation

Question 33

PREOPERATIVE MONITORING ALLOWS: • Adequate anesthesia • Adequate analgesia • Adequate immobilization • Early notice of trends, which may develop into life threatening conditions

Question 34

PERIOPERATIVE ANTIBIOTICS • If surgical sites are properly prepped, patients with healthy immune systems should be able to resist infection by most surface contaminants • Perioperative antibiotics are recommended in patients receiving an implantable device, undergoing prolonged (³90 minutes) surgery, or undergoing a contaminated procedure • “Clean Surgery” does not require on-going antibiotic therapy unless there is a break in sterile technique • For patients, the risk of infection is increased when antibiotics are given incorrectly • Example: At the wrong time or using the wrong dose

Question 35

PERIOPERATIVE ANTIBIOTICS CONTINUED... • If perioperative antibiotics are given, it should be administered within 1 hour before the first incisions • Ensure peak blood and tissue concentrations are reached before the incision is made • Re-administered antibiotics every 90 – 120 minutes during anesthesia • Based on the half-life of the antibiotic chosen • Prophylactic antibiotics should be discontinued within 24 hours after surgery • Obtaining cytology is the gold standard for any antibiotic selection

Question 36

EXAMPLES OF WHEN TO USE ANTIBIOTICS • General Procedures: • Treatment of severely contaminated or traumatized wounds • Implants [ie: Mesh, bone plate, pacemaker] • Respiratory Procedures: • Resection of infected lung • Gastrointestinal Procedures: • Enterotomy with necrotic segment • Pancreatic abscess

Question 37

SURGICAL SITE CLOSURE • Suture vs. Staples • Keeps the skin margins closed • Good skin apposition • Evaluate incision healing prior to removal • Normal removal time is 10 – 14 days later

Question 38

MAINTAINING STERILITY BEFORE AND DURING SURGERY • Proper gowning and gloving • Surgery team member should face the sterile field • Back of gown is not considered sterile • Do not touch or lean over a non-sterile area • Arms and hands should remain above waist level and below shoulder level • Arms should not be folded • Clasp in front of body [above waist] • Sleeves should be considered sterile from 2 inches above the elbow to the stockinette cuff

Question 39

POST-OPERATIVE CARE • Aid healing • Minimizes risk of additional corrective surgeries • Speeds recovery • Vital to a successful surgery outcome

Question 40

IMMEDIATE POST-OP CARE: ANESTHETIC RECOVERY • Move patient to a warm, dry area and monitor vital signs every 15 minutes until patient is sternal • Keep patient is sternal recumbency during recovery • Turn side to side frequently to prevent pooling of fluid in recumbent side • Remove endotracheal tube when swallowing/chewing aka when they get their gag reflex back. • Prevents regurgitation and vomiting. w/o gag reflex, aspiration pneumonia results • Do not return to kennel until able to maintain body temperature and hold itself in sternal position

Question 41

IN HOSPITAL POST-OP CARE: DVM • Full physical examination and evaluation of parameters [daily] • Appearance • Attitude • Appetite • Hydration Status • TPR • Signs of Pain • Surgical Incision Monitoring • Look for clinical signs of infection, seroma, hematoma, suture break down, and wound dehiscence • Allows you to adjust treatment plan if needed

Question 42

IN HOSPITAL POST-OP CARE: LVT • LVT’s will be your second pair of eyes when you are not with the patient • Hospitalization treatment sheet • Vitals • Fluids • Treatments • Diet • Lab Data • Make sure the sheet is signed and filled out correctly

Question 43

STORMY RECOVERY • Where many complications can occur • Delayed recovery • >30 minutes since termination of anesthesia --> hypothermia, slows down metabolism. Need to find happy medium between waking up too quickly or too long. • Rapid and complicated recovery • Dysphoria • Pain • Emergency delirium • Bladder distension • Fear, Anxiety, Stress [FAS]

Question 44

STORMY RECOVERY – DYSPHORIA • State of unease due to agitation and anxiety • Seen with pure mu opioids • Morphine, Hydromorphone, Fentanyl, Methadone • Vocalization, panting, difficulty settling down, or restlessness • Naloxone – carefully titrated • Multiple doses may be needed since it has a short duration or action • Butorphanol

Answer 44

which drug is most likely to cause dysphoria in a patient had Trazodone as the correct answer. The correct answer is Morphine and those that selected Morphine received full credit for the question.

Question 45

STORMY RECOVERY – PAIN • Unpleasant sensory and emotional experience that is associated with actual or potential tissue damage • Observe posture and facial expressions • Determine whether your patient is painful vs. dysphoric • When was last analgesic dose and what is the drugs duration of action? • Does the patient need additional analgesia? • Determine how painful procedure was • Gently palpated affected surgical area • Analgesic are needed with a high pain score • Opioids [Morphine, Fentanyl, Hydromorphone, Methadone] • NSAIDs [Carprofen, Meloxicam, Onsior

Question 46

STORMY RECOVERY – EMERGENCY DELIRIUM • State of mental confusion and psychomotor agitation marked by: • Hyperexcitability, restless, thrashing, and vocalization • Occurs in the immediate recovery paid [right after inhalant anesthesia is discontinued]s • Patients do not interact with humans and are unaware of environment • Thrash uncontrollably and require immediate intervention to prevent injury • Propofol • 0.5-1mg/kg IV [SLOW}

Question 47

determine if extra sedation is needed • Trazodone • 5-10mg/kg PO ~30-60 minutes prior to high anxiety event • Gabapentin • 20mg/kg PO ~30-60 minutes prior to high anxiety event • Low-dose acepromazine • 0.01mg/kg IV – cats and dog • Low-dose dexmedetomidine • 0.001mg/kg IV – cats and dogs

Question 48

Post-operative care at home

Answer 48

Question 49

Discharge instructions • Hospital and contact information • Patient information • Anesthesia side effects • Food and water instructions • Medication instructions • Home care instructions • Complications • Recheck