The Recovery Period

Question 1

Define what is meant by the Recovery Period

Answer 1

Period between the cessation of the administration of anaesethetic and the time the patient can maintain sternal recumbency

Question 2

What did the study by (Brodbelt, 2006) discover?

Answer 2

That over 60% of anaesthetic fatalities occured during the recovery period

Question 3

List 6 factors that effect the duration of the Recovery period

Answer 3

1. Length of time patient is under anaesthesia
2. Condition of patient (Critically ill, recover more slowly)
3. Age of patient (Neonates + Geriatrics will have a slower recovery)
4. Type of anaesthesia used
5. Route of administration of anasethesia used (Some drugs may have persisting effects or predispose the patient to Hypothermia)
6. Patient’s body temp

Question 4

Name 5 factors that may prolong a patient’s recovery time

Answer 4

1. Age (Neonate or Geriatric)
2. Low body temp
3. Health status (Critically ill or disease)
4. Type of anaesthesia used
5. Route of adminstration of anaesthesia used (IM etc)

Question 5

List these stages in the correct order, when a patient is recovering from sugery.

A) HR inc > RR inc > Central eye position > Inc RR volume > Palpebral, Pedal + Ear flick reflexes Inc
B) RR inc > Central eye position > Palpebral, Pedal + Ear flick reflexes Inc > HR inc
C) HR inc > RR inc > Palpebral, Pedal + Ear flick reflexes Inc > Central eye position > Inc RR volume

Answer 5

A) HR inc > RR inc > Central eye position > Inc RR volume > Palpebral, Pedal + Ear flick reflexes Inc

Question 6

True or False.

During the Recovery period, the stages progress back through the anaesthetic stages from deep > moderate > light analgesia.

Answer 6

True

Question 7

These stages progress back through the anaesthetic stages from deep to moderate to light anaesthesia:

A) Heart rate increases
B) Respiratory rate increases
C) Respiratory volume increases
D) Eye position rotates centrally
D) Reflexes such as the palpebral, pedal and ear flick become stronger.

Name 7 other signs you may see during the recovery period.

Answer 7

1. Shivering
2. Swallowing
3. Chewing
4. Attempting to lick
5. Voluntarily lifting of head
6. Opening eyes
7. Vocalising

Question 8

When should the patient be extubated?

Answer 8

When they regain their swallow reflex

Question 9

When should you extubate a Cat + Why?

Answer 9

1. When they regain their ear flick, but before their swallow reflex
2. As they can go into laryngospasm

Question 10

Why is timing important when extubating a bracycephalic?

Answer 10

1. Because they are at higher risk of Upper Airway Obstruction
2. Due to their stenotic nares, elongated soft palates, hypoplastic tracheas + redundant pharyngeal tissue
3. So too early can develop severe airway obstruction
4. But too late and they will chew or damage the ET tube > causing trauma to their airway

Question 11

What must you remember to do to the ET tube before extubating a patient?

Answer 11

Deflate the cuff

Question 12

Once the patient is extubated, what position should you place the patient in?

Answer 12

Lateral or Sternal recumbency

Question 13

Why must you pull the tongue out, after extubation?

Answer 13

To prevent the tongue from rolling back into the mouth + obstructing the airway

Question 14

True or False.

The method by which drugs are metabolised and eliminated from the body varies according to the drug used.

Answer 14

True

Question 15

How are injectable drugs metabolised + excreted?

Answer 15

1. Metabolised by the Liver
2. Excreted by the Kidneys

Question 16

True or False.

Most injectable drugs are metabolised by the liver and excreted by the kidneys via urine. Some of these drugs are excreted unchanged.

Like Ketamine in Cats.

Answer 16

True!

Question 17

During metabolism + excretion, what type of drug is redistributed from the brain > other tissues, like Adipose tissues?

Answer 17

Barbituates

Question 18

If drugs like Barbituates (during metabolsim + excretion) are redistrubuted from the brain > other tissues (Like adipose) what can this do to the body, during recovery?

Answer 18

1. The patient can regain consciousness
2. Whilst the drug it still in the adipose tissues
3. So full excretion of from the body can take a while to be eliminated, after recovery

Question 19

What route are inhalational agents such as Sevo + Isolurane generally eliminated by?

Answer 19

Respiratory tract

Question 20

True or False.

It should be noted that patients with known renal or hepatic dysfunction may take shorter time to metabolise and excrete drugs.

Answer 20

False.

It will take them longer, as they are unable to metabolise + excrete the drug.

Question 21

Why may recovery be delayed in patients who have recieved antagonist drugs, to reverse some components of anaesthesia?

Such as; Naloxone, Atipamezole + Flumazenil.

Answer 21

1. Because they don’t reverse everything involved in the anaesthetic event, as reversing sedation isn’t the same as reversing anaesthesia
2. Antagonists wake-up the brain - but don’t fix temp, BP, drug clearance or oxygenation
3. Full recovery depends on total physiological stability, not just consciousness

Question 22

What does Naloxone reverse?

Answer 22

Opioids

Question 23

What does Atipamezole reverse?

Answer 23

Alpha-2-Agonists

Question 24

What does Flumazenil reverse?

Answer 24

Benzodiazepines

Question 25

What does the mnemonic '**WAKE**' stand for in this? *"Reversal WAKES the mind, but BODY needs TIME"*

Answer 25

* W = **Wakefulness returns** * A = **Analgesia may be lost** (Especially Naloxone) * K = **Kinetics of other drugs still ongoing** * E = **Stability (physiological) still needs to catch up**

Question 26

What should be monitored during recovery?

Answer 26

1. **CV status** - MMs, CRT + pulses 2. **Airway patency** 3. **Effectivenses** of **Resp effort** - measure SpO2 4. **Cranial nerve reflexes** - establish the level of consciousness + establish when extubating 5. Body temp 6. Presence of pain 7. Status of wound or op site 8. All parameters checked + recorded w/any concerns, reported to the VS 9. Presence of urine + faeces recorded + patient moved if poss - to prevent soiling

Question 27

True or False. The degree of pain the patient may experience, isn't just affected by the patient's individual pain tolerance but by the surgery the patient has undergone.

Answer 27

True

Question 28

Invasive surgery, such as a Thoracotomy or major Orthopaedic surgery may cause: A) Mild or less pain B) Moderate pain C) Severe pain

Answer 28

C) Severe pain

Question 29

A patient has presented with an **open fracture**, following an **RTA**, may feel: A) Mild or less pain B) Moderate pain C) Severe pain **After** surgical repair/stabilisation of a fracture.

Answer 29

A) Mild or less pain

Question 30

A **poor surgical technique** may **tissue trauma**, leading to: A) Mild or less pain B) Moderate pain C) Severe pain Post-operatively.

Answer 30

C) Severe pain

Question 31

True or False. The provision of adequate perioperative analgesia will not influence the degree of pain shown by the patient.

Answer 31

False. The provision of adequate perioperative analgesia **will** also influence the degree of pain shown by the patient.

Question 32

What are the **2 most common drugs** used in **Multimodal** analgesia?

Answer 32

1. Opioids 2. NSAIDs

Question 33

True or False. When using Multimodal anaesthesia, such as the use of Opioids + NSAIDs, LA or Dissociative technique be used to complement.

Answer 33

True! LA + Ketamine (DA) can greatly complement pain relief, by multimodal analgesia.

Question 34

List **4** potential **causes** of ***prolonged*** recovery

Answer 34

1. **Prolonged activity of drugs** 2. **Hypothermia** 3. Severe pain 4. Pain relieving surgery > resting

Question 35

Give an example of **prolonged activity of drugs**, that may cause a prolonged recovery period.

Answer 35

**ACP** in patients with **renal or hepatic disease** will have a **slowed metabolism or excretion**, prolonging their recovery period

Question 36

How can **Hypothermia** can a **prolonged** recovery period?

Answer 36

1. **Reduced immune system** 2. Reduced **clotting function** 3. **Act** of **shivering** leads to inc O2 consumption > **hypoxaemia**

Question 37

**Despite** the **physiological** issues that **severe pain** can cause in recovery, what can the **psychological** causes have?

Answer 37

Depression!

Question 38

List **4** reasons for **Excitation** or **Stormy** recovery

Answer 38

1. Pain 2. **Convulsions** 3. Epilepsy 4. **Hypoxia**

Question 39

What is pain **associated with** during Excitation or Stormy recovery?

Answer 39

* The **emergence from** the **influence** of **anaesthetic drugs** * (Should be short-lived)

Question 40

True or False. In patients where recovery is **stormy** it may be necessary to **administer additional analgesia** or **sedation** under veterinary direction.

Answer 40

True!

Question 41

What is considered advisable to administer to **Bracycephalics** during the recovery period, if they are more prone to **Hypoxia**?

Answer 41

Oxygen!

Question 42

Name **5 methods of Oxygenation** that be administered to patients with **Hypoxia**?

Answer 42

1. Oxygen tent/kennel 2. Mask 3. Flow-by 4. **Nasal catheter** 5. **Tracheostomy tube**

Question 43

Summarise the RVN's 11 general responsibilities during recovery of a patient

Answer 43

1. Maintain **observations** regularly – remember the **relative risk of complications** during recovery + **remain diligent**. 2. Observe **monitor + record TPR** ensuring the **airway** remains **patent**. 3. Ensure that **ventilation is adequate** to **avoid hypoxia** + **provide O2** if any doubt. 4. **Monitor** for r**eturn of cranial nerve reflexes** + return of **consciousness**. 5. May include **extubating** of the patient – once **appropriate level of gag reflex** is present (consider *cats vs brachycephalics*) 6. **Avoid hypothermia** by keeping the patient warm + monitoring body temperature. 7. Monitor for **signs of pain** 8. **Monitor op wound site** for signs of **complications or interference**. 9. Monitor for **urination, defaecation, eating + drinking prior** to **discharge**. 10. Keep patient **comfortable**, provide **padded bedding** - **recumbent** patients should be **turned Q2hrs** to avoid **hypostatic congestion.** 11. **Report** any **abnormalities** to the veterinary surgeon

Question 44

When can a patient go home?

Answer 44

Only when VS + RVN is satisfied the patient is **fully** recovered from anaesthesia + surgery

Question 45

What should owner's be **warned** of, during recovery?

Answer 45

1. Likely to be **drowsy** 2. Any particular **wound complications** they should be aware of

Question 46

What 2 things is it helpful to provide owners with, upon discharge?

Answer 46

1. **Written instruction** of post-op care 2. **Emergency contact number**

Question 47

List some examples of **drugs with analgesic properties** that may be **given** in the **pre**, **peri** or **post-op** period

Answer 47

1. Meloxicam 2. **Carprofen** 3. **Buprenorphine** 4. **Fentanyl** 5. Methadone 6. Morphine 7. Pethidine 8. **Ketamine infusion**

Question 48

List some factors that can **lead to** a **slow** recovery

Answer 48

1. **Duration** of **procedure** 2. **Condition** of patient 3. **Age** of patient 4. **Drugs used** 5. **Hypothermia**