Transcript PATIENT PREPARATION - Dr. Roberta Dev Anand

PATIENT PREPARATION
CHAPTER 2 Part 1
PATIENT PREPARATION
• The LVT has numerous responsibilities in the pre-anesthetic period.
The pre-anesthetic period is _______________________
______________________________
• This period can be from minutes to weeks
PRE-ANESTHETIC RESPONSIBILITIES OF
AN LVT:
• SEE BOX 2-1 pg. 6 for more info…
FEELING OVERWHELMED?
MINIMUM DATABASE
 ANESTHESIA IS NOT A COOKIE CUTTER PROCEDURE: ____, ______,
_____, & ___________ play a role in the selection of anesthetic agents
and techniques
 Every patient should have a minimum database, which would ideally
include:
_______________________
 _______________________
________________________
TAKING THE PATIENT HISTORY
 DO’s:
 Be thorough
 Be effective at framing questions to gain the most information
 Schedule an appointment several days before the planned procedure
 DON’Ts:
 Don’t ask ______or ______ questions
 For example, how can you reframe this question: “Does your dog drink a lot of water?”
 Don’t ask ________ questions
 For example, how can you reframe this question: “ Your dog doesn’t drink very much
water does he?”
TAKING THE PATIENT HISTORY
• What questions should I ask?
TAKING THE PATIENT HISTORY
 SIGNALMENT: includes ________, ______, ______, _______, and
_______________
 This information influences the anesthetic plan
 SPECIES & BREED
 Each species has unique responses to anesthetic agents. Drug doses will vary
between species.
 Examples:
 Horses and cats are more sensitive to ________ than dogs and ruminants
 Cats can tolerate some drugs given alone, while the same drug may cause seizure-like activity
in dogs
 Large animals are prone to respiratory depression
 Boxers & giant breeds are more sensitive to ____________
 __________________ are sensitive to barbiturates
 ___________________breeds are difficult to intubate
TAKING THE PATIENT HISTORY
 AGE
 Very young animals-less than ______ wks of age-are much less capable of
metabolizing injectable drugs because necessary ________________are
not fully developed.
 Young animals are also more prone to ________________ and
____________
 Geriatric patients-who have reached ________ of the normal lifespan- may
have difficulty metabolizing drugs due to _________ or ___________
failure
TAKING A PATIENT HISTORY
• SEX & REPRODUCTIVE STATUS
• Confirming the sex of the animal is especially important in cats
TAKING THE PATIENT HISTORY
• SEX & REPRODUCTIVE STATUS
• For males, confirm the presence of both testicles in the scrotum
• For females, ask about the possibility of pregnancy, the last estrous cycle, check
for a spay scar or a tattoo
TAKING THE PATIENT HISTORY
• SEX & REPRODUCTIVE STATUS
• For females, ask about the possibility of pregnancy.
• Determine the client’s wishes if the animal is found to be pregnant
CONSENT FORM
Have the client sign a consent form/estimate.
This should be done in person. By phone is an
option, although this is not ideal. Make sure a
witness also hears the authorization.
A consent form reviews ______________,
_____________, ______________, and
______________for the owner.
Some forms also state that a drug will be used on
their animal in an extra-label manner.
* If possible, have the owner read the estimate and consent
form before the day of surgery.
PATIENT DISPOSITION & LEVEL OF
CONSCIOUSNESS
• Anxious or aggressive animals may require a combination of drugs for
sedation
• Fearful or aggressive animals may require a different route of
medication administration (oral, induction chamber)
PATIENT DISPOSITION & LEVELS OF
CONSCIOUSNESS
 Level of consciousness refers to the patient’s responsiveness to stimuli
or how easily it can be aroused.
 BAR, QAR
 ____________ – mild decrease in LOC & can be aroused with minimal
difficulty
 ____________ – more depressed patients that cannot be fully aroused
 _____________– sleeplike state; can only be aroused with painful
stimuli
 _______________ – cannot be aroused and is unresponsive to all
stimuli including pain.
PHYSICAL EXAM
• HYDRATION STATUS – several parameters can be used to
assess hydration:
•
•
•
•
•
Skin tenting
Mucous membrane color, moisture
Position of globe in the orbit
HCT/TP
Serial body weight measurements
• Sudden loss of ___ kg corresponds to ____ L fluid loss
PHYSICAL EXAM
• HYDRATION STATUS
• Dehydration increases the risk for hypotension, poor tissue perfusion, &
kidney damage
PERCENT DEHYDRATION
PHYSICAL SIGNS
<5%
Not detectable
5-6%
Mild loss of skin elasticity
6-8%
the above + dry m.m., depressed globes within orbits
8-10%
The above + more persistent skin tent, increased PCV/TP
10-12%
The above + dry, pale m.m, CRT >2sec
12-15%
Signs of shock, death
PHYSICAL EXAM
• RE-HYDRATION
• Ideally, dehydration should be corrected prior to surgery:
• (Wt in kg)(1000 mL/kg)(% dehydration)
• EXAMPLE:
A 33 lb dog that is 9% dehydrated, needs _______mL
33 lb /2.2 = 15 kg
(15 kg)(1000 mL/kg) = 15,000 mL
(15,000 mL)(0.09) = 1350 mL
PHYSICAL EXAM
• For animals that require ongoing fluid therapy postoperatively:
• RE-HYDRATION
• Daily fluid requirement in mls = _____ ml x body wt. in kg
• Estimation of ongoing losses = ml of fluid losses x 2
PHYSICAL EXAM
• EXAMINE STRUCTURES OF THE HEAD
• ORAL CAVITY:
• Check mucous membrane color, CRT: If gums are pigmented check the
conjunctiva, inner vulva, prepuce
PHYSICAL EXAM
• EYES & EARS
• Look for signs of dehydration, check pupillary light reflexes
• Check the ears for signs of infection, or growths
PHYSICAL EXAM
AUSCULTATION: listen to the rate, rhythm, and sounds
of the heart and lungs
Normal resting heart rate:
Dogs: 60-180
Cats: 110-220
Normal respiratory rate:
Dogs: 10-30
Cats: 25-40
Rhythm: listen for normal sinus rhythm vs. Sinus
arrhythmias & other arrhythmias
Abnormal sounds: crackles, wheezes, evidence of
respiratory distress (flared nostrils, open-mouth breathing,
respiratory stridor)
Listen to all 4 quadrants of the chest
PHYSICAL EXAM
• PULSE: assess the strength and the rate
• The femoral artery is the easiest location to palpate a pulse
• Other locations: metatarsal, metacarpal arteries
• A strong or weak pulse loosely correlates with blood pressure
• Pulse deficits may indicate _____________
PHYSICAL EXAM
WEIGHT: assign a body condition score (either
use 5 scale or 9 scale)
Drug doses and IV fluid rates are based on
weight in addition to species. DON’T
ESTIMATE. Weigh accurately.
Use a pediatric scale (if available) if <5 kg; use
gram scale if <1 kg
Compare current weight to previous weights.
PHYSICAL EXAM
• WEIGHT
• OBESE ANIMALS can experience dyspnea, they can be
_____________________, harder to assess _____________,
and difficult to __________.
• Obese animals do NOT need a higher dose of anesthetics.
Although the body mass is larger, the central nervous
system is not.
• THIN ANIMALS can be at risk for __________ and may have an
underlying condition causing the weight loss.
PHYSICAL EXAM
• OTHER SYSTEMS:
•
•
•
•
Body Temperature: 100.0°-102.5° for dogs & cats
MS: signs of lameness, pain
Lymph: evaluate size of lymph nodes
Abdomen: evaluate for tense or painful abdomen, evaluate organ size, presence
of fluid or gas
• Repro: evaluate testicles, mammary glands, vulva, prepuce
• Integument: check for bruising, petechiae, pyoderma
FASTING
• Fasting usually begins the night before surgery
• Adult dog or cat: Withhold food for _______hours before surgery. Water
is withheld anywhere from _______ hours before surgery, depending on
the veterinarian’s preference.
• Neonate and pediatric patients (<8 wks): Much shorter fasting period
(depending on species, could be 4-6 hrs, or no fasting) to avoid
dehydration or hypoglycemia.
• GI surgery: Withhold food for _______ hours, water for __________
hours.
• Why fast?
• Fasting is done to avoid __________________ during surgery or
recovery which can cause esophagitis, respiratory obstruction, or
___________________.
FASTING
 In addition to not fasting long enough, it is not safe to have
animals fasted for too long.
 This usually refers to animals refusing to eat for various reasons usually when the surgery is not elective: serious GI
obstructions/perforations, or in the situation where 2 surgeries are
performed several days apart and the animal does not want to eat
between the surgeries.
 Prolonged fasting leads to a longer recovery period, delays
healing, and puts the animal at risk for other medical problems (
ex: hepatic lipidosis).
 Options include hand/syringe feeding, inserting feeding tubes, or
total parenteral nutrition.
PATIENT PREPARATION
• Be sure the animal is properly identified
• Use a cage card or ID collar or BOTH
DIAGNOSTIC TESTS
DIAGNOSTIC TESTS
• The extent of the diagnostic testing will depend on the clinic, the
owner, and what is ideal for the patient
• It is important to provide the most complete and affordable testing
available
DIAGNOSTIC TESTS
 COMPLETE BLOOD COUNT:
 _______________
 used to determine the blood’s ability to deliver oxygen to tissues. Increases
usually indicates dehydration (which leads to increased viscosity of the
blood, poor perfusion and decreased cardiac output). Decreased levels
usually indicates anemia.
 PCV less than 25% in a dog or less than 20% in a cat should be reported immediately
 __________________
 usually indicates dehydration if increased. Decreased values may indicate
decreased production by the liver or a loss through the renal, hepatic or GI
systems. Decreased levels can lead to increased drug potency.
 Values of less than 4.0 should be reported immediately
 ___________________
 used to evaluate red blood cell & white blood cell morphology and platelet
estimation.
 Report all decreases in platelet count or abnormal coagulation test results
DIAGNOSTIC TESTS
 URINALYSIS:
 _____________________
used to detect evidence of dehydration or renal insufficiency
 ______________________
used to detect diabetes
 _______________________
can be seen with urinary tract infections and crystalluria
(can also be normal in small amounts)
 USE THESE RESULTS IN CONJUNCTION WITH OTHER TESTS
DIAGNOSTIC TESTS
 CHEMISTRY PANEL:
 MOST COMMONLY EVALUATED PARAMETERS PRE-OPERATIVELY
ARE:
 ALT: _______
 ALP (or ALKP): _______, ____________, __________
 BUN: ____________
 Creatinine: ___________
 Glucose: _________________
 Electrolytes: Na, K, Ca
The more parameters that are evaluated, the better picture we have of
the patient.
DIAGNOSTIC TESTS
CLOTTING TIMES:
Not commonly performed for routine procedures unless
coagulopathies are suspected such as in breeds that are
commonly affected by hereditary coagulation disorders.
PT, (A)PTT
In-clinic testing is performed by either performing a
Buccal Mucosal Bleeding Time (BMBT), a short nail
trim to the quick, or placing whole blood in a plain
red top. Blood should clot within _____ minutes.
DIAGNOSTIC TESTS
• ECG
Evaluates _____________ activity of the heart, pattern, rhythm
Perform if heart disease is suspected, there is a history of trauma,
electrolyte abnormalities, or if the animal is geriatric
DIAGNOSTIC TESTS
• RADIOGRAPHS
• not routinely done in private practice, but are indicated with dyspnea,
abnormal heart/lung sounds, or history of recent trauma.
• HEARTWORM TEST – it is important to know heartworm status before
undergoing anesthesia
DETERMINATION OF (ASA) PHYSICAL
STATUS
•Classification based on history, physical
exam, and diagnostics performed
•Classification is objective and can change
with animal’s status
•Correct problems before surgery if possible
Category
Physical condition
Examples
PI
Minimal risk
Normal, healthy animal
w/o underlying disease
Spay, neuter, declaw, hip
rads
P II
Slight risk, minor
disease
Slight to mild systemic
disturbances; animal
compensate
Neonates, geriatric,
obese, skin tumors,
uncomplicated hernia,
local infection
P III
Moderate risk, obvious
disease
Moderate systemic
disease, mild clinical
signs
Anemia, moderate
dehydration, fever, lowgrade murmur or heart
disease
P IV
High risk, significant
disease
Preexisting systemic
disease
Severe dehydration,
shock, uremia, high fever,
severe heart or lung
disease, diabetes,
emaciation
Life threatening disease
PV
Extreme risk, moribund that may not be corrected
by surgery, animal may
not survive 24 hrs
Advanced heart, liver,
kidney, lung, or terminal
disease, severe shock,
head injury, severe
trauma
2yr old, mixed breed intact male weighing 12lbs; BCS: 2/5,
T-103.5, HR-160, RR-40; 8% dehydrated
Bloodwork: PCV: 35%, TP: 7.6 g/dl
What anesthetic status would you give this dog?
Preanesthetic Pic of the Day
Based on the picture, what anesthetic category would you place
Oscar in?