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Recovery concerns and pain scoring (Proceedings)

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Aug 01, 2008

The recovery period is a very important period where vigilance is the key as complications such as hypoventilation; hypoxemia, hypothermia, pain, and excitation are not uncommon. It would be wrong for an anesthetist to think that his/her job is over once he/she turned off the anesthetic. In this chapter we will look at common complications, their cause and possible ways to prevent and/or treat them.

Recovery

There are many factors involving a safe smooth recovery for the small animal patient. If most recoveries are quite, some can go horribly wrong. All animals recovering from anesthesia must be monitored continuously for any potential complications. The environment should be quiet and comfortable; Cages should be padded with some form of cushion such as foam mats, towels, rubber pads, etc. It is desirable to use materials that are easy to clean as animals can defecate, urinate, reflux, vomit, as well as ooze from surgical wounds. Cleaning/disinfectant materials should be easily accusable. There should be items available such as body warming devices, thermometers, needles and syringes, heparinized saline, extra drugs such as analgesic, sedatives. It is desirable to have the recovery area be a separate room from the rest of the hospital that does not have much traffic. Some recovery areas have dimmer lighting for patient comfort as well. There should be an emergency cart around as well as oxygen for managing potential cardiopulmonary complications. This can be used to house all supplies necessary for patients recovering. If possible try also no to mixed species so that cats would not be stressed because of barking dog for example.

Recovery Complications

Patient not regaining consciousness

Causes for prolonged recovery are multifactorial. To list a few: drug overdosage, injection of an opioid (morphine) just before recovery, poor metabolism, and hypothermia.

Extubation Concerns

When the patient begins to regain certain reflexes as well as muscle tone, the anesthetist needs to be aware of the timing of extubation; the removal of the endotracheal tube. In preparation for this, deflate the cuff of the tube and try to position the animal in a position where ventilation is easy for the patient. Open up the airway by hyper-extending the head. Remove the tie used to hold the tube to the head. A strong swallow usually indicates the time for extubation. If airway obstruction does occur, injectable drugs should be close by to administer to the patient to aid in re-intubation. This is critical time as there are many potential complications that may arise. Some complications associated with extubation are damage to the larynx (more common in small species such as cat, ferret and rabbit). This can come from pulling out a cuffed tube, or frequent manipulation of the tube as it is being pulled out. You may also see hematoma formation and edema. A patient with increased jaw tone may make it difficult to pull the tube out. The tube can be chewed in half if the patient becomes too light; patient can then aspirate the distal portion. If the procedure involved blood or if there is reflux material in the mouth, the larynx needs to be flushed with saline, and dried prior to extubation so as to avoid aspiration. Visually examine the larynx with a laryngoscope before patient begins to regain jaw tone. In consideration of upper airway obstruction; patients that have brachycephalic syndrome or any other disease process that inhibits proper function of the upper part of the respiratory system should be considered an increased risk and delivery of oxygen via face mask should take place in recovery. Try to keep the tongue pulled forward out of the mouth as this may obstruct the airway. These patients may also need ventilatory support. The use of steroids and non-steroidal inflammatory drugs has been used to keep inflammation/ swelling down in the upper airway to protect patients from obstruction and reversal of anesthetic drugs may be necessary to expedite recovery. Cats can laryngospasm if they become too light, so do not delay the extubation process. Emergency tracheotomy may be necessary to gain access to an airway if there is obstruction for any reason.