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
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
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
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
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
6
Q
What are 6 recovery complications?
A
- Pain
- Dysphoria
- Hypo- or hyperthermia
- Hypoventilation
- Hypoxemia
- Prolonged recovery
7
Q
What are 6 signs of pain in a recovering patient?
A
- TPR changes
- Vocalization
- Posture/gait
- Interaction w/ caregivers
- Guarding of painful site
- Behavior change
8
Q
What are the different consequences of pain?
A
- CV–increased cardiac work load
- Resp–hypo- or hyperventilation, hypoxemia
- GI–ileus
- Renal–oliguria
- Hematologic–risk of thromboembolism
- Immunologic–impaired immune function
- Psychologic–anxiety, fear
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
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
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
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
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
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
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
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
- Address underlying problem before reversing analgesic drugs
- Aggressive re-warming if hypothermic
- Maintain BP–administer inotropes or vasopressors if necessary
- Supplement dextrose if hypoglycemic
- Correct electrolyte derangements
- Administer transfusion (whole blood, bRBC) if indicated
- Reverse drugs
- 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
Complications in equine recovery?
* Pain
* Hypothermia
* Hypoventilation--\> hypoxemia
* Airway obstruction (remember: horses are obligate nasal breathers!)
* Anemia, electrolyte disturbances
* Myopathy/neuropathy
26
What are the two types of equine recovery?
* 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
What are the various methods of assisted recovery in equines?
* 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
Equine sedatives--indications and types
* 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
What are some additional considerations during equine recovery?
* 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
What are some pain complications in equine recovery?
* 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
Equine recovery complications--hypothermia
* 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
Equine recovery complications--hypoxemia
* 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
Equine recovery complications--airway obstruction
* 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
Equine recovery complications--weakness
* 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
Rhabdomyolysis--myopathy: what is it, what are the signs, and what is the treatment?
* Muscle injury secondary to hypoperfusion
* Hard muscles
* Sweating
* Trembling
* Myoglobinuria
* Pain
* Treatment
* Fluid
* Analgesics
36
Equine neuropathy: nerves involved, prevention, treatment?
* 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
Ruminant recovery--general
* 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
Ruminant recovery strategies
* 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!
