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Anesthesiology > Recovery > Flashcards

Recovery Flashcards

1
Q

Small animal recovery–extubation: what position should the animal be in? What 2 things should you ensure? If there is no regurgitation, what needs to be done?

A
  • Sternal recumbency
  • Ensure patent and clean airway
  • Deflate endotracheal tube cuff, remove after swallow or cough
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2
Q

What needs to be done if regurgitation occurs during extubation?

A
  • Postural drainage (nose low)
  • Swab posterior pharynx with gauze (or suction) before awakening
  • Remove ET tube with cuff inflated
    • Do not force the tube; deflate a small amount if needed
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3
Q

During small animal recovery, what specific physiologic monitoring is required (as indicated)? When should you stop?

A
  • TPR in all patients
  • Pulse ox in brachycephalics, upper or lower airway disease, pulmonary pathology, etc.
  • Blood pressure in patients with hemorrhage, sepsis, hypovolemia, etc.
  • Monitor patient closely until able to hold head upright and maintain sternal recumbency
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4
Q

What are 3 cautions to be aware of when monitoring a recovering small animal?

A
  • Bandages around neck or head can lead to upper airway obstruction in a sedated patient–monitor closely and remove bandage if necessary
  • Bandages around thorax may cause breathing difficulty–cut bandage or loosen if necessary
  • Brachycephalics commonly develop upper airway obstruction in recovery
    • Monitor
    • Have an extra ET tube ready for re-intubation in an emergency
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5
Q

What does ‘supportive care’ entail during small animal recovery?

A
  • Use active and passive warming to maintain or raise body temp as needed
  • Stimulate patient if needed to increase level of consciousness
    • Change position (roll legs under when switching laterals)–more physiologic position
    • Auditory and tactile stimulation
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6
Q

What are 6 recovery complications?

A
  1. Pain
  2. Dysphoria
  3. Hypo- or hyperthermia
  4. Hypoventilation
  5. Hypoxemia
  6. Prolonged recovery
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7
Q

What are 6 signs of pain in a recovering patient?

A
  1. TPR changes
  2. Vocalization
  3. Posture/gait
  4. Interaction w/ caregivers
  5. Guarding of painful site
  6. Behavior change
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8
Q

What are the different consequences of pain?

A
  1. CV–increased cardiac work load
  2. Resp–hypo- or hyperventilation, hypoxemia
  3. GI–ileus
  4. Renal–oliguria
  5. Hematologic–risk of thromboembolism
  6. Immunologic–impaired immune function
  7. Psychologic–anxiety, fear
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9
Q

When anticipating surgical pain, what are the 3 different levels and what is included in each?

A
  • Most painful
    • Thoracotomy, amputation, ear resection, pelvic repair, cervical disc
  • Moderately painful
    • Mastectomy, mandibulectomy, T-L disc, fracture stabilization, cranial abdominal procedure, ovariohysterectomy, enucleation, corneal transplant
  • Mildly to moderately painful
    • Tracheostomy, aural hematoma, castration, caudal abdominal procedure, phacoemulsification
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10
Q

What should be considered when treating pain?

A
  • Keys to analgesia
    • Multi-modal
    • Pre-emptive
  • Anticipate pain based on procedure
    • Surgical site
    • Tissue trauma
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11
Q

Pain vs. dysphoria

A
  • Opioid dysphoria
    • Humans: ‘uncontrollable/unpleasant thoughts, difficulty w/ concentration, unpleasant bodily sensations, anxiety, nervousness’
  • A painful patient will be quiet with additional opioids
  • A dysphoric patient will become distressed with additional opioids
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12
Q

Pain vs. dysphoria–considerations (4)

A
  • What analgesics have been administered?
    • Dose, duration of action
  • Procedure?
    • What is the expected level of pain?
  • Patient temperament and breed?
    • Anxious patients will likely continue to be anxious post-op
    • Some breeds seem more susceptible to dysphoria (Huskies, malamutes)
  • Surgical site pain?
    • Gently palpate the surgical site–reaction suggests behavior is pain-related rather than dysphoria
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13
Q

Pain vs. dysphoria–strategies

A
  • Administer short-acting opioid (e.g. Fentanyl)
    • Worse? –> likely dysphoria
    • Better? –> likely pain
  • Alpha2 agonist
    • Will treat dysphoria AND pain
  • Acepromazine
  • Benzodiazepine
  • Opioid antagonist
    • Butorphanol (mu antagonist)–will maintain some analgesia (agonist at kappa receptor)
    • Naloxone–titrate carefully to avoid severe pain caused by removal of opioid analgesia
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14
Q

What are the 2 types of hypothermia? What are the causes of each?

A
  • Short-term
    • Increased O2 demand
    • Prolonged recovery
    • Discomfort
  • Long-term
    • Delayed healing
    • Infection
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15
Q

What equipment is most/least effective/dangerous when treating hypothermia via active warming?

A
  • Most effective
    • Forced hot air device (BAIR hugger)
    • Radiant heat device
    • ‘Hot dog’
      • CAREFUL–can cause burns in certain circumstances
  • Less effective
    • Circulating warm water blanket
    • Heated cage
    • Heated objects (fluid bags, etc.)
  • Dangerous
    • Heating pads
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16
Q

Who is most susceptible to hyperthermia? How can you treat it?

A
  • Opioid-treated cats, MRI in obese furry dogs
  • Routine cooling procedures
    • Remove bedding from cage
    • Fan
    • Wet towels
  • Can reverse mu-agonists if severe (cats)
17
Q

Hypoventilation: diagnosis? Causes?

A
  • Diagnosis
    • Arterial blood gas
    • EtCO2 monitor
    • Clinical signs
  • Causes
    • Drugs
    • Airway obstruction
      • Brachycephalics
      • Collapsing trachea
      • Laryngeal/tracheal surgery
      • Debris in airway (fluid, sx sponge, food, blood)
    • Pain–esp. thoracotomy, rib fractures
18
Q

Treatment for hypoventilation

A
  • Delay extubation and continue IPPV as needed
  • Clear airway
  • Reverse drugs
19
Q

Hypoxemia–diagnosis? Causes?

A
  • Diagnosis
    • Pulse oximetry
    • Arterial blood gas
  • Causes
    • Most common: airway obstruction (hypoventilation), pulmonary pathology (V/Q mismatch)
20
Q

Treatment for hypoxemia?

A
  • Address underlying cause
  • Position properly–sternal recumbency or good lung up
  • Warming (shivering increases O2 demand)
  • Oxygen support–increase FiO2
    • Flow-by O2
    • O2 cage
    • Nasal O2
    • Positive pressure ventilation
      • Short-term: re-anesthetize and institute IPPV w/ 100% O2
      • Long-term: ventilator
21
Q

How long should prolonged recovery take?

A
  • Depends on:
    • Patient
    • Specific procedure and duration
    • Drugs administered
22
Q

What are the prolonged recovery ‘rule-outs?’

A
  • Hypothermia
  • Hypotension
  • Hypoglycemia
  • Electrolyte derangements
  • Anemia
  • Hypoxemia and/or hypoventilation
  • Drugs
  • Neurologic disease
    • Pre-existing
    • Anesthesia-related
      • Cats especially–blindness, stupor, coma–d/t cerebral hypoxia (remember O2 delivery to tissues is dependent on CO and blood O2 content
      • Avoid mouth gags in cats–compromise cerebral arterial blood flow
23
Q

What are 7 treatments for prolonged recovery?

A
  1. Address underlying problem before reversing analgesic drugs
  2. Aggressive re-warming if hypothermic
  3. Maintain BP–administer inotropes or vasopressors if necessary
  4. Supplement dextrose if hypoglycemic
  5. Correct electrolyte derangements
  6. Administer transfusion (whole blood, bRBC) if indicated
  7. Reverse drugs
    1. Remember, analgesia will also be reversed in the case of opioids
24
Q

Equine recovery–general

A
  • Horses will usually try to stand before they are physically capable
  • Most dangerous time in equine anesthesia
    • For patient AND personnel
  • Potential for catastrophic injury (fracture, luxation, airway obstruction), minor injuries common (contusions, lacerations)
  • Anecdotal evidence often prevails–scientific evidence lacking on best practice
  • Often governed by personal preference, limits of the facility, and experience of personnel
25
Q

Complications in equine recovery?

A
  • Pain
  • Hypothermia
  • Hypoventilation–> hypoxemia
  • Airway obstruction (remember: horses are obligate nasal breathers!)
  • Anemia, electrolyte disturbances
  • Myopathy/neuropathy
26
Q

What are the two types of equine recovery?

A
  • Free recovery
    • For generally healthy horses without orthopaedic disease
    • Short anesthetic event (1-2 hrs) w/o complications
    • Dangerous or unhandled horse
  • Assisted recovery
    • Old, weak, systemically ill patients
    • Those with orthopaedic disease
    • Those where airway obstruction is a concern, esp. sinus or dental sx
    • Ophtho sx
27
Q

What are the various methods of assisted recovery in equines?

A
  • Hand
    • For foals and other small horses (depending on personnel, but usually <100 kg)
    • One person on head (w/ halter and lead), one on tail
  • Ropes inside recovery stall
    • Head and tail ropes attached to rings in wall for leverage
    • One person on head rope and one on tail
  • Ropes outside recovery stall
    • Head and tail ropes fed through openings in wall
    • Personnel holding ropes are outside the stall
  • Sling recovery
    • For extremely debilitated patients, fracture repair
  • Pool recovery
    • For fragile orthopaedic repairs
    • Not commonly available
28
Q

Equine sedatives–indications and types

A
  • Recovery from triple dip usually smooth and rapid
  • Need sedative to smooth recovery from gas anesthesia
  • Alpha2 agonist
    • Xylazine or romifidine preferred (detomidine and dexmedetomidine may cause more ataxia)
  • +/- acepromazine
    • For healthy anxious or high-strung patients needing additional sedation
    • Low dose
    • Give while on table to allow BP monitoring
29
Q

What are some additional considerations during equine recovery?

A
  • Place elasticon over shoes or rough feet to increase traction
  • Bandages to protect surgical sites
  • Eye mask after ophthalmic procedures
  • Quiet environment
    • Decrease in auditory stimuli may prevent early attempts to rise
  • Dark stall or towel placed over eyes
30
Q

What are some pain complications in equine recovery?

A
  • NSAIDs
    • Mainstay of equine pain relief
    • Long duration
    • Option for PO administration
  • Alpha2 agonists
    • Short duration
    • Commonly used for visceral (colic) pain
  • Butorphanol
    • Short duration
    • Commonly used for visceral pain
  • Morphine/Meperidine
    • Short duration, concern for ileus
    • May be better for somatic pain
31
Q

Equine recovery complications–hypothermia

A
  • Large body mass = takes longer to cool/warm
  • Maintain body temp throughout procedure to avoid need to warm during recovery (will take a long time)
  • Cover patients with sheets, use Bair hugger (large blankets available) during sx
  • Increase recovery stall temp if possible
32
Q

Equine recovery complications–hypoxemia

A
  • Ample evidence that hypoxemia is very common during equine recovery
  • Supplemental O2 recommended for healthy patients, required for sick patients or those w/ respiratory compromise
  • Demand valve O2 while intubated
  • Nasal O2 once extubated
  • Can remain in place during recovery, usually will be dislodged by patient at some point
33
Q

Equine recovery complications–airway obstruction

A
  • Check for nasal edema before recovery
    • Apply intranasal phenylephrine
    • Nasopharyngeal tube
  • Concerned about airway patency or aspiration?
    • Tape ETT in and extubate once standing
    • Obstruction can still occur upon extubation
  • Personnel safety important–do not get in the way of panicking horse
  • Always be prepared for tracheostomy
34
Q

Equine recovery complications–weakness

A
  • Hypocalcemia, hypoglycemia, hypokalemia, anemia will lead to muscle weakness
    • Could contribute to fatal injury
    • At the very least, recovery will not be pretty
  • Check bloodwork before recovery and correct disturbances while still on the table
35
Q

Rhabdomyolysis–myopathy: what is it, what are the signs, and what is the treatment?

A
  • Muscle injury secondary to hypoperfusion
    • Hard muscles
    • Sweating
    • Trembling
    • Myoglobinuria
    • Pain
  • Treatment
    • Fluid
    • Analgesics
36
Q

Equine neuropathy: nerves involved, prevention, treatment?

A
  • Radial nerve
  • Facial nerve
  • Prevention is key
    • Padding, positioning
    • Remove halter during procedure
  • Provide supportive care until signs resolve (weeks in most cases)
    • Splint forelimb to prevent knuckling
    • Keep corneas lubricated
37
Q

Ruminant recovery–general

A
  • Usually ‘smart’–do not attempt to stand until physically ready and able
  • Complications similar to small animals w/ the addition of:
    • Regurgitation (common) +/- aspiration
    • Bloat
38
Q

Ruminant recovery strategies

A
  • Maintain sternal recumbency
  • Postural drainage, pharyngeal swabbing, suction
  • Delayed extubation, cuff inflated
    • Wait until trying to chew on tube
  • Pass stomach tube if needed to relieve gas bloat
  • For cattle
    • Prop with hay or straw bales
    • Tie head to stall
    • Safety first!

Anesthesiology (16 decks)

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