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 ruminantsCats can tolerate some drugs given alone, while the same drug may cause seizure-like activity

in dogs Large animals are prone to respiratory depressionBoxers & 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 post-operatively:

•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: 60-180Cats: 110-220

Normal respiratory rate:Dogs: 10-30Cats: 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

• ECGEvaluates _____________ 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, low-grade 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

P V

Extreme risk, moribund

Life threatening disease 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

What anesthetic status would you give this dog?

2yr old, mixed breed intact male weighing 12lbs; BCS: 2/5,T-103.5, HR-160, RR-40; 8% dehydratedBloodwork: PCV: 35%, TP: 7.6 g/dl

Preanesthetic Pic of the Day

Based on the picture, what anesthetic category would you place Oscar in?