PATIENT%20PREPARATION

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PATIENT PREPARATION
CHAPTER 2 Part 1
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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

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PRE-ANESTHETIC RESPONSIBILITIES OF AN LVT

• SEE BOX 2-1 pg. 6 for more info

FEELING OVERWHELMED?
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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
• _______________________
• _______________________
• ________________________

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TAKING THE PATIENT HISTORY

• DOs
• Be thorough
• Be effective at framing questions to gain the
  most information
• Schedule an appointment several days before the
  planned procedure
• DONTs
• Dont ask ______or ______ questions
• For example, how can you reframe this question
  Does your dog drink a lot of water?
• Dont ask ________ questions
• For example, how can you reframe this question
  Your dog doesnt drink very much water does he?

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TAKING THE PATIENT HISTORY

• What questions should I ask?

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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

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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

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TAKING A PATIENT HISTORY

• SEX REPRODUCTIVE STATUS
• Confirming the sex of the animal is especially
  important in cats

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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

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TAKING THE PATIENT HISTORY

• SEX REPRODUCTIVE STATUS
• For females, ask about the possibility of
  pregnancy.
• Determine the clients wishes if the animal is
  found to be pregnant

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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.

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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)

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PATIENT DISPOSITION LEVELS OF CONSCIOUSNESS

• Level of consciousness refers to the patients
  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.

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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

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PHYSICAL EXAM

• HYDRATION STATUS
• Dehydration increases the risk for hypotension,
  poor tissue perfusion, kidney damage

PERCENT DEHYDRATION PHYSICAL SIGNS
lt5 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 gt2sec
12-15 Signs of shock, death
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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

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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

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PHYSICAL EXAM

• EXAMINE STRUCTURES OF THE HEAD
• ORAL CAVITY
• Check mucous membrane color, CRT If gums are
  pigmented check the conjunctiva, inner vulva,
  prepuce

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PHYSICAL EXAM

• EYES EARS
• Look for signs of dehydration, check pupillary
  light reflexes
• Check the ears for signs of infection, or growths

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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

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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 _____________

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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. DONT ESTIMATE. Weigh
  accurately.
• Use a pediatric scale (if available) if lt5 kg
  use gram scale if lt1 kg
• Compare current weight to previous weights.

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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.

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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

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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
  veterinarians preference.
• Neonate and pediatric patients (lt8 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
  ___________________.

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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.

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PATIENT PREPARATION

• Be sure the animal is properly identified
• Use a cage card or ID collar or BOTH

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DIAGNOSTIC TESTS
COMPLETE BLOOD COUNT
ECG
CLOTTING TIMES
RADIOGRAPHS
URINALYSIS
CHEMISTRY PANEL
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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

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DIAGNOSTIC TESTS

• COMPLETE BLOOD COUNT
• _______________
• used to determine the bloods 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

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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

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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.

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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.

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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

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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

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DETERMINATION OF (ASA) PHYSICAL STATUS

• Classification based on history, physical exam,
  and diagnostics performed
• Classification is objective and can change with
  animals status
• Correct problems before surgery if possible

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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
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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?
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Preanesthetic Pic of the Day
This is Oscar
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(No Transcript)
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This is Oscar's foot
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• Based on the picture, what anesthetic category
  would you place
• Oscar in?