In the end, pre-op precautions have a lot to do with what we keep telling our clients: An ounce of prevention is worth a pound of cure. Trying to cut corners in the anesthesia and surgery world can lead to countless medical and legal problems. Let’s review 10 all-too-common mistakes to avoid before taking a patient to surgery. 1. Money Creating an accurate surgical estimate is an art form, especially when you can’t predict the outcome of surgery and the duration of hospitalization. We don’t want to scare clients away, yet we don’t want to mislead them with a lowball estimate. It is wise to err on the safe side and give owners a worst-case scenario estimate as the high end of the range. If clients can barely afford surgery, they surely will be upset if they can’t provide a longer stay in the hospital if it’s required. So be upfront. With nonroutine cases, ensure your estimate takes the unexpected into consideration. 2. Radiographs (Part 1) Not taking appropriate pre-op radiographs could lead to situations that are tricky at best. Imagine the following story. Cody, a 12-year-old golden retriever, has a splenectomy after abdominal X-rays reveal a mass. Five days later, you call the client with biopsy results: The mass is malignant. To your surprise, the owner tells you that you will actually see Cody later that afternoon anyway. She made an appointment because Cody has been doing poorly since surgery. Signs include ADR, anorexia, and coughing. Later that day, you perform chest radiographs, and surprise … Cody’s lungs are full of round masses. Surely the mets were there five days earlier. But for the sake of saving money (because of your “kindness” or the client’s financial limitations), you are now in a lose-lose-lose situation with no possible good outcome. Of course, the events depicted in this story are fictitious. Any similarity to any patient, living or dead, is merely coincidental. 3. Review Your team may have done everything right. Blood work has been performed. Radiographs have been taken. Yet all of this doesn’t do anyone any good if you don’t take the time to review the blood work and radiographs before surgery. Anyone who has spent a day in a veterinary clinic understands how such a seemingly obvious omission could happen. Reasons for forgetting include being overbooked, distracted, interrupted, rushed, or tired. To bypass such avoidable oversights, consider including a checklist in each medical record. List every single step involved, from the signature of the consent form to turning oxygen on, and ensure that everything is checked off before making your skin incision. 4. Side The consent form and the checklist should verify the side of the problem: a mass, an ACL tear, or the leg to be amputated. We’ve all experienced how confusing it can be for a pet owner to understand which side is which. If there is any risk of confusion, have the owner mark the correct surgery site(s) by shaving a lock of hair or coloring the fur over the area with a permanent marker. Verify the side of an orthopedic case with the owner and be sure to write it on consent forms and medical records. 5. Asepsis Asepsis tends to be casual because of a common belief: “We’ve done it like this for 20 years and we’ve never had a problem.” Unfortunately, that often means that the level of asepsis of the OR, IV catheter sites, and surgical sites progressively drops to less than appropriate standards. Keep your OR clean and your standards as high as possible to limit any potential contamination or infections. There is nothing funny about a MRSA infection! 6. Radiographs (Part 2) Always take pre-op radiographs before foreign body removal or a cystotomy. Stones and foreign bodies can migrate. If X-rays are not taken immediately before surgery, you may be surprised by your findings, or lack thereof, during surgery. The most classic example is “bladder” stones that become urethral stones. 7. Fear For fractious, excitable, or muscular animals, tender loving care, low-stress handling, and sedation are critical to reducing fear, anxiety, and stress. In addition, these practices provide an opportunity to perform a more thorough exam. For example, it magically becomes much easier to feel a drawer sign or a luxating patella in a relaxed patient. 8. Communication The time to discuss possible complications and risks of anesthesia and surgery is before the procedure. Many clients are terrified of anesthesia. Explain which steps you take in your hospital to minimize the risk. Do you perform pre-op blood work? Do you use safe drugs? Do you use gas anesthesia? Is your patient intubated? Do you keep anesthetized patients on IV fluids? How are patients monitored? Does the patient have a dedicated anesthesia nurse? If so, explain to your client how all of these precautions decrease (but don’t eliminate) the risks of complications. 9. Pain It’s time to embrace modern pain management. Using the same “recipe” for every single patient is so last century. Appropriate premedication minimizes discomfort and provides enough sedation to decrease fear, anxiety, and stress. In turn, it reduces the depth of anesthesia needed during surgery. The potency of pain medications is chosen based on the anticipated level of pain. Therefore, for your patients’ sake, please don’t use butorphanol in every case. There are several more potent and very safe opioids that are more appropriate for procedures more involved than a spay, a neuter, or a tooth extraction. Buprenorphine, morphine, hydromorphone, and fentanyl can be used safely and with great success. 10. Efficiency The better you prepare before anesthesia and surgery, the more efficient you will be during the procedure. Again, a checklist is helpful here: anticipated drugs, supplies, special equipment, additional instruments, etc. Ensure your equipment is working properly: suction, cautery, monitoring devices, etc. Also double check the level of gas anesthetic in the regulator, the amount of IV fluids you may need during surgery, and the color of the soda lime. In the end, these pre-op precautions have a lot to do with what we keep telling our clients: An ounce of prevention is worth a pound of cure. Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. Visit his websites at DrPhilZeltzman.com and VeterinariansInParadise.com. Nikki Schneck, a technician near Pottsville, Pa., and Kelly Serfas, a certified veterinary technician in Bethlehem, Pa., also contributed to this article.
