Patient Preparation (Part 1)

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Patient Preparation
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1

Role of the Veterinary Anesthetist

MPD (minimum patient database); proper pt fasting; preinduction pt care; all supplies are available; all equipment is in working order; preanesthetic medication

2

Why is communication important?

Makes clients feel more comfortable/less anxious; clients are more confident in your work; shows you care; informed client can better handle unexpected results.

3

Components of an MPD

Pt Hx--including signalment, PE (exam), PA (assessment), and a preanesthetic diagnostic workup

4

How and why do you confirm the scheduled procedure?

Verbally; prevents tragic accidents; know the specifics (exact location of tumors, owner's wishes re: cytology/histology, decisions during the procedure)

5

Tragic accidents

Anesthetizing the wrong pt; performing an unnecessary procedure; not performing a scheduled procedure

6

Patient Hx is info

obtained from the client; determine the following: info given freely, duration, severity/volume, frequency, appearance/character

7

What types of questions do you ask?

Not those that can be answered w/yes or no; not leading questions.

8

Components of Signalment

Breed, reproductive (status), age, sex, species ("BRASS")

9

Signalment: Species: Horses & cats are more sensitive to

opioids; use w/caution @ lower doses or don't use at all

10

Signalment: Species: Cats require a lower dose of

lidocaine, but are more resistant to the effects of phenothiazine than dogs

11

Signalment: Species: Recovery in horses

Inhalants are more difficult in horses than in other species.

12

Signalment: Species: Anticholinergics

should be avoided in ruminants

13

Signalment: Species: Ventilation support is needed for

large animals (can't ventilate on their own).

14

Signalment:Species: Excessive airway secretions(blockages) are common in

cats & ruminants

15

Signalment: Species: Exotic animals

are handled differently

16

Signalment: Breed: Differences in Anatomy & Physiology

May affect the animal's response to anesthetic agents/procedures.

17

Signalment: Breed: Sighthounds

Sensitive to barbiturates

18

Signalment: Breed: Boxers & Giant Breeds

Sensitive to acepromazine

19

Signalment: Breed: Terriers

Resistant to acepromazine

20

Signalment: Breed: Brachiocephalic dogs

Difficult to intubate

21

Signalment: Breed: Draft horses

sensitive to sedatives

22

Signalment: Age

plays a role in drug choice in neonates, pediatrics, and geriatric patients

23

Signalment: Sex & Reproductive Status

Male or female? Intact or neutered? Used for breeding? Pregnant?

24

Signalment: Sex & Reproductive Status: Stallions

acepromazine causes priapism for days

25

Signalment: Sex & Reproductive Status: Pregnant Cows & Ewes

very sensitive to xylazine

26

Patient History: Medications

Current or past? May influence the effect of the anesthetic agents. Sympathomimetics, tricyclic antidepressants, antibiotics, monoamine oxidase (MAO) inhibitors, antihistamines

27

Patient History: Allergies/Drug Rx

Record in the history to prevent future administration. Cats: longer ketamine recovery;dogs: behavioral change after ace sedation.

28

Patient History: Preventive Care

Vx: date & type; fecal analysis/parasite control; heartworm status (dogs); FeLV/FIV in cats; Tetanus toxoid in horses.

29

Patient History: Past/Current Illnesses

Preexisting disease? Anorexia, V/D, coughing, sneezing, PU/PD, tenesmus, dysuria?General signs of illness? Stabilize prior to anesthesia. Change in behavior: CNS disorder, pain, systemic illness. Exercise intolerance: heart disease, anemia, musculoskeletal pain. Weakness: a nonspecific sign. Fainting/seizures: often difficult to differentiate; have different etiologies. Unexplained bleeding: bruising, blood in feces/urine; prolonged bleeding after injury. Associated w/coagulation disorders; increased risk of intra- and post-operative hemorrhage.

30

Patient History: Other Considerations

Written estimate; signed consent form.

31

Why is a signed consent form necessary?

Legally required; informs of risks; standard forms are available; should include owner's daytime phone number. Permission to use CPRC; list extralabel drugs used.

32

What is a physical exam and who performs it?

An evaluation to determine diagnosis and treatment planning. The veterinarian.

33

What is a physical assessment and who performs it?

An evaluation to provide patient care, respond to patient needs, detect changes in patient condition. The vet tech.

34

Why are the PE and PA necessary?

Ensures high quality patient care.

35

How to complete a PE/PA.

Examine the entire patient. Use a consistent technique (head to tail or organ system).

36

Systems most affected by anesthetic agents.

Cardiovascular, nervous, and pulmonary

37

Patient Identification

Cage tags, patient ID collars, documented external characteristics in the medical record.

38

External characteristics

species, breed, size, hair coat length, color

39

Why is body weight so important?

Must be accurate for proper dosing

40

Body weight < 5kg

pediatric scale

41

Body weight < 1 kg

gram scale (exotics)

42

body weight of a horse (kg)

[heart girth (cm)2 x length (cm)]/11880

43

When is an animal weighed?

immediately before an anesthetic procedure; compare with previously recorded weight.

44

Body condition score

assessment of pt weight w/ideal weight

45

On a 1-9 scale in dogs, what's the ideal weight assessment?

4-5

46

On a 1-9 scale in cats, what's the ideal weight assessment?

5

47

On 1-5 scale...

3 is ideal.

48

Cachexia

score of 1. Defined as extreme physical wasting

49

Obesity

score of 5 on a 1-5 scale. Defined as extremely overweight.

50

Body condition influences

patient management

51

Fat animals are harder to anesthetize because

they're harder to awaken

52

Hydration assessment

skin turgor, placement of eye in orbit, mucous membrane color, refill time, moisture level (tacky, sticky, etc.), heart rate and pulse strength; correct hydration abnormalities prior to anesthesia; young & obese pts appear more hydrated, whereas old & cachetic pts appear less hydrated; panting dries out the mucous membranes.

53

Level of Consciousness (LOC)

To assess brain function, response to stimuli, BAR, QAR, lethargic, obtunded, stuporous, comatose

54

Obtunded is defined as

depressed, unable to be aroused

55

Pain score

assesses pt's level of pain and helps select preanesthetic/anesthetic agents

56

Pain medication

is not an option. Use it!

57

Body temp

Rectal thermometer. Elevated:inflammation; Decreased: systemic disorders.

58

General condition

assess from a distance: gait, temperament, activity level; will affect the choice of anesthetic agents & methods of administration

59

Exterior surfaces

hair, skin, lymph nodes, mammary glands (visual &manual exams), body openings (odor, discharge), eyes, ears, nose, throat.oral cavity (EENT)

60

Pupillary Light Reflex (PLR) types

normal, direct, and consensual reflexes

61

Pupillary Light Reflex (PLR):normal

both are the same size

62

Pupillary Light Reflex (PLR): direct and consensual

both pupils react equally to light

63

Pupillary Light Reflex (PLR): consensual but not direct

when light is shone into the pupil, the eye does not react; however, the other eye does

64

Pupillary Light Reflex (PLR): direct but not consensual

when light is shown into the pupil, the eye reacts; however, the other eye does not

65

Cardiovascular System Exam: Heart rate

beats per minute; auscultation of left chest wall (3rd, 4th, 5th intercostal space); obese animals, panting dogs; purring cats; pediatric patients; exercise or stress of handling.

66

Cardiovascular System Exam: Heart rhythm: Normal Sinus Rhythm (NSR)

Dogs, cats, rodents,ferrets, rabbits, horses, ruminants

67

Cardiovascular System Exam: Heart rhythm: Sinus Arrhythmia (SA)

Dogs, horses, ruminants. Affected by respiration.

68

What is a First Degree AV Heart Block?

card image

1 blip, then normal QRS complex. Detected only on an ECG tracing.

69

What is a Second Degree AV Heart Block?

card image

More than 1 blip between QRS complex; periodic block of conduction through the AV node resulting in skipped heartbeats.

70

Preanesthetic workup

no one standardized diagnostic fits every patient

71

Considerations for a preanesthetic workup

geriatric, elective procedure, sick pt, based on age, history, PE; financial considerations

72

When is the preanesthetic workup performed?

after pt history has been taken and the PE has been completed

73

Preanesthetic diagnostic tests/procedures

CBC, urinalysis, blood chemistry, blood coagulation screens, ECG, radiography, other tests as deemed necessary

74

Physical Status Classification is based on

an evaluation of the MPD; rates pt anesthesia risk

75

American Society of Anesthesiologists Physical Status Classifications

Classified as P1 - P5, with P1 being the most minimal risk & P5 being the most extreme risk. P1 & P2 use standard anesthetic protocol

76

Which classifications use standard anesthetic protocol?

P1 - P2

77

Which classifications use special protocols & stabilization?

P3 - P5

78

What is the main consideration factor with anesthetic protocols?

familiarity with anesthetic agents

79

Why place an IV catheter?

fluid admin., rapid IV access in an emergency, CRI of drugs/anesthetic agents, admin. of vesicants; sequential admin, of incompatible drugs

80

A vesicant is

an agent that causes damage to surrounding tissues (sloughing)

81

IV catheter types

Through the needle; over the needle

82

The type of catheter most often used is the:

over the needle

83

Most commonly used over the needle catheter is the 16-24 gauge, 3/4 to 2" catheter for small animals

Whereas the most commonly used over the needle catheter is the 16-16 gauge, 5 1/4" catheter for large animals

84

Considerations for Catheter Placement and Maintenance

Length, size, location, admin. set w/injection port; free flowing fluids, minimal pt. & catheter movement, slow admin; saline flush

85

Steps in placing an IV catheter in a small animal patient

clip area over vein; prepare area using aseptic technique; place tape over catheter hub; hold off vein; tense skin, position catheter; advance catheter assembly thru skin; advance it further to firmly seat in the vein; advance catheter over the end of the needle; remove needle; apply pressure; attach T-port, cap, or set line to the catheter hub; secure catheter w/tape. Flush w/saline; twist the tape into a 'bowtie'; crisscross tape under & around the catheter hub; apply ointment to the plastic strip; apply plastic strip over the site of insertion; secure catheter w/tape; create tension loop w/tape.