Ana Procedure Part 2 Discharge.pdf

Recovery, Post-op Considerations, Discharge NSCI5711 – Intro to Veterinary Anaesthetic and Surgical Procedures Recovery Video - atdove.org https://www.vetstream.com/treat/canis/video/anesthesia-induction-and-recovery @ 3:28 h...

Recovery, Post-op Considerations, Discharge NSCI5711 – Intro to Veterinary Anaesthetic and Surgical Procedures Recovery Video - atdove.org https://www.vetstream.com/treat/canis/video/anesthesia-induction-and-recovery @ 3:28 https://goo.gl/images/K3eiuQ What do we mean by “the recovery period”? Recovery The recovery period is one of the most HIGH risk periods of anaesthesia – WHY? Unless there is a dedicated recovery nurse in the clinic, observation of the animal is usually poor. Monitoring during the recovery period tends to be reduced – it should be increased! Anaesthetic support such as oxygen supplementation is usually withdrawn, whilst the cardiovascular and respiratory depressive effects of the gaseous drugs continue. Body temperature is poorly maintained and heat provision usually withdrawn. Transition From theatre to ward, or recovery area Two people at all times – why?? Critical time as animal disconnected from gas and oxygen Monitor closely - have assistance and extra drugs on hand! https://goo.gl/images/fUw9QL Think about your clinic set-up?  Recovery Area Think about your clinic’s recovery area? Is it the same place that the surgery takes place? Are there other animals barking or making noise? Is it quiet, calm, peaceful? Are there other people around? Is there easy access to drugs in an emergency? Ideal Recovery Area? Ideal Recovery Area? Good temperature control Well ventilated Quiet Easily visible from the main work area Available oxygen supply Accessible power points – for warming devices and fluids Padded bedding – think about fleece vet bed? Anything else? Floor vs. cage vs. table?? Think about WHERE you want your patient to wake up If on the table, are they small enough for you to be able to restrain? If on the floor, is the area safe and can someone sit with the patient? If in the cage, will there be access to other people, drugs and assistance? https://goo.gl/images/CyCSys https://goo.gl/images/CyCSys  Oxygen Supplementation Keep oxygen only on as long as possible Disconnect from patient and flush the line first Extubation potentially an hypoxic event Helps to clear the lungs of noxious gases Extubation Extubation refers to the removal of the endotracheal tube from the animal We generally ‘extubate’ the animal once they are awake enough to be able to swallow WHY? Return of the animals pharyngeal and laryngeal reflexes Can now protect their own airway in case of regurgitation or vomiting Cats can sometimes be different – just BEFORE the return of swallow reflex. Cats have a very sensitive larynx – prone to laryngospasm if extubated late  https://goo.gl/images/9UMxa6 https://goo.gl/images/9UMxa6 Extubation Tips Keep tube cuff inflated as long as safely possible Stay calm and quiet - don’t vigorously try to wake the patient Have other people around to help Place the tube, along with all of the E.T tube tie and cuff tubing, out through the front of the canine teeth – WHY? Once extubated – what do we check for? https://goo.gl/images/BsNnef Excitement Phase Not all recoveries are smooth unfortunately! Just like the excitement stage of anaesthesia (during induction) Reverse order… animal passes through this stage again when waking Can exhibit dysphoria, thrashing, vocalisation etc. Have help on hand Ask the veterinarian in ADVANCE about what to do in this situation Is light sedation a possibility? Continued Monitoring Anaesthesia monitoring does NOT end when the procedure is over! Remember that the recovery period can be more dangerous than the anaesthesia during surgery time Keep monitoring CONTINUOUSLY until the patient is extubated and can lift their head Monitor vitals every 5 minutes until the patient awake enough to keep their head up and seems alert and responsive Someone needs to be around to check on post-anaesthesia patients regularly, even after they seem awake. Continued Monitoring General attitude/subjective assessment Heart rate Respiration rate Respiration effort Mucous membrane colour Capillary refill time Temperature Blood pressure ECG? Temperature Hypothermia is a very common problem encountered with our anaesthetised patients. WHY?? Drugs that cause vasodilation (acepromazine, propofol, and inhalants) = heat loss at the extremities and limbs Unconsciousness = lack of movement and body can no longer regulate own temperature Blood loss Open body cavities during surgical procedures Cold (i.e. room temperature) intravenous fluids Cold environment in the operating room. Oxygen flow is cold Temperature What is normal for a DOG? 38.2 – 39.2 degrees Celsius* What is normal for a CAT? 38.2 – 38.6 degrees Celsius* **minor variations from different sources here, this from the BSAVA 5th ed. Pg 376  Temperature – why do we care? Many robust studies suggest that hypothermia significantly increases recovery time Hypothermic animals have a decreased ability to process anaesthetic drugs and therefore take longer to recover. Cellular and tissue dysfunction = delayed healing Post-operative bleeding – hypothermia affects platelet function and coagulation Some studies even link wound infections to hypothermia Bryant, Susan. 2011 Anesthesia for Veterinary Technicians, Wiley-Blackwell. Ames, IA Buggy, D., & Crossley, A. (2000). Thermoregulation, mild perioperative hypothermia and post-anaesthetic shivering. British Journal of Anaesthesia,84(5), 615-628. doi:10.1093/bja/84.5.615 Pottie, R. , Dart, C. , Perkins, N. and Hodgson, D. (2007), Effect of hypothermia on recovery from general anaesthesia in the dog. Australian Veterinary Journal, 85: 158-162.  Temperature Care not to overheat our patients, especially if still sedated. Usually assisted warming up to 37.5 degrees, then monitor from there What are some ways we can warm a patient on recovery? Blankets Warm air blowers (Bair Huggar) Hot hands (care!) Water blankets or beds Fluid warmers Heat pads (care!) Insulation blankets and wraps others? https://goo.gl/images/GXG96f https://goo.gl/images/edHvVf https://goo.gl/images/F3qgHb https://goo.gl/images/TfXA7s Intravenous Fluid Therapy Ideally until animal fully recovered and are eating and drinking on their own. Dehydration delays recovery and healing Fluid losses in surgery – how?? Talk to your Veterinarian about what type of fluid and what rate to use https://goo.gl/images/YxAJec  Analgesia Pain has long been recognized in human medicine as having a negative effect on several systems in the body. It has been shown to: https://goo.gl/images/xkg7X7 Amplify the body’s stress response to injury Cause several metabolic and endocrine changes Slow healing and patient recovery Analgesia Why is keeping on top of a patients pain especially important for animals?? -They can’t tell us how they feel https://goo.gl/images/xkg7X7 -They can’t take their own medication - Animals are very stoic and do not show and express pain like we do - Animal welfare and ethical implications - We don’t want them to be in pain! Pain Scoring What is it?? Several pain scoring scales or pain management guidelines have been developed for use in veterinary patients. They can be used for serial monitoring of pain levels in hospitalized patients – meaning we can keep track of pain throughout the day Limitations include the fact that pain scoring is subjective, all animals react differently, and the behaviour of animals can interfere with the scoring, especially in a stressful clinic environment. https://todaysveterinarypractice.com/todays-technician-pain-assessment-in-dogs-cats/ Haemorrhage Patients should be monitored closely for signs of post operative complications, such as haemorrhage. How can we tell if a patient is bleeding internally? Pale MM and slow CRT https://goo.gl/images/rrg5E3 Dullness, lethargy, weakness Bruising Mentation and demeanour Swelling around wound, e.g. swollen tight abdomen Rarely will you see the incision gushing with blood, if you do, there is a VERY urgent problem. Nutrition Nutrition is fundamental in regards to an animals health, recovery and overall wellbeing. RER = Resting Energy Requirement The patients resting energy requirement (RER) is the amount of energy required for maintaining homeostasis while the animal rests quietly in a stress free, neutral environment (BSAVA, pg 307). RER = 70 x (bodyweight in kg)^0.75 Nutrition – things to consider? What kind of surgery has the animal had? - Anything around the neck, oesophagus, trachea? - G.I tract surgery? Was the animal eating before surgery? Does the animal have allergies or a specific diet from home? Feeding tubes? Careful with food aversions! Hygiene and Comfort Urination Diarrhoea and faeces Vomiting Spilled water and food Discharge from wounds All post-operative animals need to be checked regularly and cleaned if needed, they will NOT be performing normal cleaning behaviours themselves. Urine Scalding…  Self Trauma Animals can be naughty!! Even when you think an animal is too sedated or too sleepy after their procedure! Self trauma to wound or incisions, licking, biting, scratching and rubbing on the cage door Chewing out sutures… If you think its possible – put an E-collar on them! What could we do differently? What could we do differently? Isoflurane – should this be turned off so early? Draining bedding – i.e. Vetbed ET tube cuff, should we deflate it this early? Tube pulled before swallow reflex return – better timing here? Animals not contained in cages and multiple animals on one bed to recover No direct monitoring of each individual animal – temp, HR, RR etc? Anything else? Discharge When is it ok? When can the patient be discharged? When the VET says it’s ok? When the patient has ‘adequately’ recovered from surgery – what does this look like? After a discharge consultation? Once the patient can walk, eat, hold head up? NO ‘ONE SIZE FITS ALL’ RULE ** At the very minimum the patient must be aware of their surroundings, be alert and responsive, able to walk and lift their head and have their pain under control ** Discharge Consults Can be either a vet consult or a vet nurse consult Ensure owner is given CORRECT information Medications are explained to the owner & CORRECT instructions are on the label as well as being verbally relayed to the client Follow up appointments may be made Re-check client phone numbers Discharge form – Details regarding post-operative care, next appt, medications, bandages, diet & expectations. Discharge Tips Ensure you complete all info with owner before you get their pet – WHY? Give only forms & information relevant to the patient – be concise. Give written instructions along with the verbal ones - WHY? Make sure the pressure bandage is OFF before the animal leaves the clinic Make sure they know when to remove sutures/bandages etc. ***Explain the reasons WHY*** Examples of Discharge Instructions Keep inside warm & quiet for the evening after anaesthesia - Unable to maintain body temp very well, unable to protect self out on roads, fights etc. Feed half a small meal & offer water - Some animal may vomit post anaesthesia, this can be a normal reaction but must subside by next day If not eating, try some warm wet food to entice, & MUST eat following morning or should call the clinic for advice Clinic phone number & After-hours phone number with what to look for tailored for the patient Sutures/Staples 10-14 days Medications Bandages MUST stay dry (give cover) Suitable diet post surgery – tailored to the patient Elizabethan Collar & appropriate instructions – explain what can happen if they don’t want to use one. Exercise instructions Revisits, Re-checks and Calls Patient returns for a revisit post surgery – this may be the next day or the following week or when Vet requires If revisit is next day, there will be temp check, heart rate check, wound/surgical area check etc. Phone clients who are not due to come in – check recovery, appetite, toileting, behaviour, incision site etc. Be sure to record EVERYTHING you say to the client & do to the patient. Put it directly into the computer system.