Presentation on theme: "Pre, Peri and Post-Operative Care"— Presentation transcript:
1Pre, Peri and Post-Operative Care ASR Certification Prep
2Pre Operative Care Pre-Surgical Planning: Pre-surgery Examination & Blood workFastingSet-up of prep area and operating roomThermo regulationAseptic PreparationAnalgesic RegimenAnesthesiaAseptic Transfer to Surgical Field
3Pre-surgery Examination Examination should include:Physical examination and blood work in large animalsCheck animal identificationTake and record temperature, HR, CRT, RR, BWCheck cage for signs of loose stool or vomitingObserve animal in home cage for normal behaviorsReview animal medical record
4All animals should have free access to water. Pre-surgical FastingRodents & Rabbits (mice, rats, guinea pigs, hamsters, rabbits): High metabolic rateNo fasting prior to surgeryRodents DO NOT have vomit reflex, no regurgitationMonogastric animals (e.g. dogs, cats, swine):Fast 6-24 hours prior to surgery Ruminants (e.g. sheep, goats, cattle)Fast for hours prior to surgery.Reduces fermentation in the rumenPlacing stomach tube reduces rumenal tympany.All animals should have free access to water.Restricting water results in dehydration and more difficult anesthesia.
5Set-up of Prep Area and OR Ensure prep area has:Working heat support on tableFunctioning anesthesia machine (if required)StethoscopeAppropriate drugs and reversal agents (analgesics and anesthetics)Functioning monitoring equipmentPrep supplies and clippersVacuumEnsure OR area has:Functioning anesthesia machine (with ventilator)Fluid support as neededEmergency supplies (Ambu bag, and crash cart supplies)
7(e.g., table tops, equipment) RECOMMENDED HARD SURFACE DISINFECTANTS(e.g., table tops, equipment)Always follow manufacturer's instructions for dilution and expiration periodsAGENTEXAMPLES*COMMENTSAlcohols70% ethyl alcohol85% isopropyl alcoholContact time required is 15 minutes. Contaminated surfaces take longer to disinfect. Remove gross contamination before using. InexpensiveQuaternary AmmoniumSodium hypochlorite(Clorox ® 10% solution)Chlorine dioxide(Clidox®, Alcide®, MB-10®)Corrosive. Presence of organic matter reduces activity. Chlorine dioxide must be fresh; kills vegetative organisms within 3 minutes of contact.Glutaraldehydes(Cidex®, Cetylcide®, Cide Wipes®)Rapidly disinfects surfacesPhenolicsLysol®, TBQ®Less affected by organic material than other disinfectantsChlorhexidineNolvasan® , Hibiclens®.Presence of blood does not interfere with activity. Rapidly bactericidal and persistent. Effective against many viruses.* The use of common brand names as examples does not indicate a product endorsement.
8Aseptic Technique Preparation of the patient Bland ophthalmic ointment to eyesremove hair from the surgery site ( #40 blade, vacuum)initial or preparative scrubPovidone-iodinefollowed by alcohol rinseChlorhexidine followed by saline rinsemove to surgical room / areafinal surgical scrub/paintPovidone-iodine followed by alcohol rinseDuraprep®, Chloraprep®sterile draping of surgical siteestablish a sterile fieldThe surgeon should direct how the animal is positioned on the table.In OR final surgical scrub should be done after the animal has been positioned and put on monitoring equipment.Establishing a sterile field: When the animal is properly positioned and antiseptically prepped for surgery, a sterile field should be created.Generally, a sterile field should be large enough to prevent accidental contamination of the incision site(s), operating team, and sterile instruments and equipment.
9Alternating disinfectants is more effective than using a single agent. RECOMMENDED SKIN DISINFECTANTSAlternating disinfectants is more effective than using a single agent.AGENTEXAMPLES*COMMENTSIdophorsBetadine®, Prepodyne®,Wescodyn®Reduced activity in presence of organic matter. Wide range of micobicidal action Works best in pH 6-7CholorhexadineNolvasan®, Hibiclens®Presence of blood does not interfere with activity. Rapidly bactericidal and persistent. Effective against many viruses. Excellent for use on the skin.* The use of common brand names as examples does not indicate a product endorsement.
10Peri-Operative Monitoring Allows: Adequate anesthesia.Adequate analgesiaAdequate immobilizationEarly notice of trends which may develop into life-threatening conditions
11Checking Anesthetic Depth ReflexesJaw toneEye position, pupil size and pupillary light responseHeart and respiratory ratesResponse to surgical stimuli
12ReflexesPalpebral (blink) - tested by lightly tapping the medial or lateral canthus of the eyePedal - Elicited by pinching a digit or footpadCorneal - Tested by touching the cornea with a sterile objectLaryngeal - Stimulated when the larynx is touched by an object.
13Parameters to Monitor (every 10-15minutes) ECG (EKG)Peripheral PerfusionPulmonary MonitoringTemperatureBlood Pressure
14ECG (EKG)An EKG measures the electric currents generated by the heart.Monitors heart functionContinuous monitoring with an EKG allows early recognition of electrical changes associated with disorders of conduction in the heart and arrhythmias that may need to be treated.
15ECG (EKG) Cardiac dysrhythmias: Tachycardia: excessive rapidity of the heartBradycardia: slowing of the heartVentricular fibrillations: total disorganization of the ventricular activity
16ECG (EKG) Premature ventricular contractions (PVCs): early contraction Heart Block: loss of or non-P-wave associated QRS complexesIndicate lack of electrical transmission in the heart
17Heart Rate Monitored by : Palpation of heart beat through chest wall Palpation of peripheral pulse for strength and qualityAuscultation of heart beat with stethoscopeElectrocardiogram (EKG, ECG) with continuous display
18Heart RateKnow the acceptable HR for the species you are monitoring. Bradycardia: excessive anesthetic depth, “too deep” vagal stimulation hypertension hypothermia drug effects elevated cranial pressure Tachycardia: inadequate anesthetic level, “too light” pain/surgical stimulation hypotension hypoxemia hypercarbia
19Peripheral Perfusion Capillary refill time (CRT) Measures the time taken for refilling blanched mucus membranesObserve the color of mucus membranesCRT should be 1-2 seconds and gums (when not pigmented) should be pinkOther sites for color are tongue, buccal mucous membrane, conjunctiva of the lower eyelid, and the mucous membranes about the prepuce or vulvaPale membranes indicate poor perfusion, blood loss, or anemiaPurple/blue membranes indicate cyanosis
20Pulse OximetryMeasures the percentage of oxygenated hemoglobin and heart rateIs broadly accurate for SaO2sensory probe needs to be placed on nonpigmented area (tongue, tail, ear ,etc.)
21Pulse OximetrySensor beams infrared light through tissue and records the absorption either of light passing through the tissue to a receiver on the other side (transmission) or reflected back to the sensor (reflectance) Reflector sensor Transmission sensor
22Pulse OximetryNormally SaO2 is 80-90% in spontaneously breathing animals and % in ventilated animalsNumbers reflect animal on 100% oxygenSaO2 readings are susceptible to lowering by positional factors (slipping away from tissue, thick tissue, pigment), vasoconstriction, drying of contact surface, and confusion with respiratory artifactWithout pulse oximetry, early hypoxia can be difficult to assess as cyanosis only becomes apparent if values fall below 85% saturation.
24End-tidal CO2 (ETCO2)Capnography measures ETCO2 concentration, at the end of an exhalationUsually somewhat lower than PaCO2A PaCO2 measurement requires blood gas analyzer and arterial blood samples.
25End-tidal CO2 (ETCO2)Accuracy is subject to mechanical factors with the breathing circuit such as volume, dead pockets, tubing diameter, gas flow, etc.Animals with ETCO2 over mm Hg will usually breathe on their ownLow ETCO2Surgical support for cleaning and autoclaving
26End-tidal CO2 (ETCO2)When displayed as a capnographic waveform much useful information may be derived such as:“Spiky” topped waves may indicate a waking animal taking short, sharp breathsPlateau with a drop to the right may indicate a leak in the circuit as the pressure of inspiration is not held
27Respiration Monitored by : Observation of chest wall movement Observation of breathing bag movementAuscultation of breath soundsAudible respiratory monitorRespiratory volume may be estimated visually, by reservoir bag inflation, or by using a ventilator or ventilometerNormal tidal volume is mL/kg/respirationNormal respiratory sounds are almost inaudible
28Respiration Normal respiratory rates can vary widely Should be evaluated along with tidal volume and respiratory trendsMay indicate an underlying physiologic changeArrhythmic breathing patterns are usually the effect of a medullary respiratory control problemHowever, some abnormal patterns may be normal in certain speciesA Cheyne- stokes pattern is normal for horse but could be sign of heart failure or brain damage.Apneustic breathing (inspiratory hold) seen in healthy cats, dogs, and animals anesthetized with ketamine
29RespirationTachypnea: inadequate anesthetic level, “too light”, pain, hypoxemia, hypercarbia, hyperthermia,CSF acidosis, drug effectsHypoventilation : Inadequate or reduced alveolar ventilation leads toAtelectasis : partial collapse of the lungPeriodic 'bagging/sighing' (every 5 minutes) throughout the procedure can prevent this.Apnea: excessive anesthetic depth, “too deep”, hypothermia, recent hyperventilation, musculoskeletal paralysis, drug effects
30RespirationHarsh noises, whistles or squeaks may indicate narrow or obstructed airways or the presence of fluid in the airways.Difficult or labored breathing may indicate the presence of an airway obstruction.An abnormally low respiratory rate (<8-10 bpm) is cause for concern. Apneic animals may need to be manually ventilated throughout the procedure at a rate of 8-12 bpm.
31Respiratory Acidosis Inadequate Elimination Of C02 Production Of C02 Exceeds EliminationCauses: Reduced Effective Alveolar Ventilationfrom:Pulmonary EdemaPneumoniaAirway ObstructionInterstitial FibrosisInadequate Ventilation(<20 Cm H20 Intra-alveolar Pressure)slow Respiratory RateHypoxemiaDiagnosis: EtCO2 > 45 mm Hg
32Respiratory Alkalosis Enhanced Elimination Of C02Elimination Of C02 Exceeds ProductionCauses: Increased Effective Alveolar VentilationFrom:High Intra-alveolar pressureHyperoxemiaHypotensionPulmonary edemaInterstitial fibrosisEndogenous catecholamines (from stress)Mechanical ventilationDiagnosis: EtCO2 < 35 mm Hg
33VentilationPressure is introduced into the trachea which inflates the lungs.Causes a significant loss in lung complianceNecessary in all procedures in the thoracic cavity.Ventilation can be severely compromised by pneumothorax, hemothorax, hydrothorax or a diaphragmatic hernia.Routine manual “bagging/sighing” of thepatient can prevent atelectis.
34Body Temperature Anesthetized animal lose the ability to thermoregulate normally.Will lose heat via loss of hair to shaving, the evaporation of prep solutions, evaporation at and chilling of tissues within surgical incisions, and vasodilatation caused by anesthetic agents/adjunctsHypothermia will prolong anesthesia recoveryShould be countered with warmed fluids, heating blankets, and towels/wrapsHyperthermia is also possible and dangerousMay be due to overheating with heating pads and tables or due to anesthesia reactions such as malignant hyperthermia in swine Anesthetized animals lose the ability to thermoregulate normallySurgical support for cleaning and autoclaving
35Body Temperature Monitor Temperature throughout surgery Ways to prevent HypothermiaKeep animal warm during inductionWarm IV Fluids and irrigating solutionsCirculating warm water/air blanketsPad between animal and metal tableHot water bags/bottles wrapped in towelCovering feet, hands, paws, & headHeat lamps
36Blood PressureBP = hydrostatic force that blood exerts on wall of vessels Systolic Pressure= pressure of blood when ventricles at maximum contraction Normal range 100 to 160mmHG Diastolic Pressure= pressure of blood when ventricles relax Normal range 60 to 100mmHg MAP= (2 x DP) + SP divided by 3 Normal range 80 to 120mmHg Pulse Pressure= systolic – diastolic Normal ~ 40mmHg
37Blood Pressure MAP < 60 mmHg is hypotension Decreased perfusion due to low BP can cause tissue ischemiaSusceptibility of tissue to ischemia depends on metabolic rate of the tissueHypertension: Systolic >180 mm Hg andDiastolic >110mm HgInadequate anesthesia, partially or fully occluded airwayControlling Blood Pressure:anesthetic levelIV fluidsBody temperature
39Blood Pressure Invasive/ Direct – accurate quantitative value Arterial catheter connected to pressure transducer
40Immediate Post-operative Care Move the animal to a warm, dry area and monitor vital signs every 15 minutes until the animal is sternal.Turn side to side frequently to prevent pooling of fluid in recumbent side.Remove endotracheal tube when swallowing/chewing this prevents regurgitation and vomiting.Do not return to home cage until able to maintain body temperature and hold itself in sternal position.
41Post-Operative CareA ”stormy “ recovery could be related to surgical pain.All animals subject to major surgery must have analgesic agents (i.e. painkillers) available to them for at least the initial hours post-surgeryProvide analgesics as directed by veterinarian.
42Post-Operative Care Daily evaluation parameters: appearance attitude appetiteHydrationTPRSigns of painSurgical Incision - for clinical signs of infection, seroma, hematoma, suture breakdown, wound dehiscence.
43Post-Operative Care Administration of drugs Suture/Staple Removal SID or QD once dailyBID twice dailyTID three times dailyQID four times dailySuture/Staple RemovalThe goal of the staples / sutures are to keep the skin margins closed.Evaluate incision healing prior to removalNormal removal time is 10 to 14 days
44References NIH website http://oacu.od.nih.gov/ARAC/surguide.pdf Duke University Animal Care and Use ProgramDoctors Foster and Smith Website