Always assume a vocal patient is in pain, such as this eight-month-old Labrador after a fracture repair.Photo courtesy Phil Zeltzman It’s easy to become complacent during anesthesia when we keep 99 percent of patients alive. However, just because a patient is alive doesn’t mean we can’t do better. What is the patient’s temperature? What is their comfort level? Did they wake up three times during surgery? Were they too deep? How was their blood pressure? How was their CO2? Here are some simple suggestions to help you improve patient care, make anesthesia safer, and help ensure a smoother recovery. 1) Bag Make sure the anesthesia bag is the correct size for your patient. Animals weighing less than 20 lbs. usually benefit from a non-rebreathing system. Keep track of your patients’ respiratory rate. If they become apneic, or they don’t breathe effectively (as evidenced by capnography), don’t hesitate to ventilate them. Remember, overweight patients can’t inflate their lungs efficiently; therefore, they are prone to hypoxemia and hypercapnia (obesity hypoventilation syndrome, a.k.a. Pickwickian syndrome). 2) Catheters Place the correct size IV catheter. Sure, it’s no big deal if a 100-lbs. patient has a 25-gauge catheter as long as there is no crisis. But if that patient becomes hypotensive or arrests, you will not have the ability to bolus fluids at the speed that may save their life. As a general rule, you should place the largest bore catheter possible. In some at-risk patients, it may be a good idea to proactively place an IV catheter in each front leg. 3) Tubes Similarly, using the appropriate size endotracheal tube is important to maintain the patient’s airway. In addition, the endotracheal tube protects against aspiration. The cuff should be lubricated while inflated to create a better seal. The cuff is deflated during intubation, and reinflated afterward. As a precaution, always leak-test the cuff before use. In addition, always ensure the patency of the tube before you use it. Small tubes especially can get clogged with secretions that have dried up. 4) Depth In addition to the “usual” vitals, assess your patient’s anesthetic depth, meaning palpebral response, eye position, and jaw tone. Otherwise, it may be difficult to know if he or she is over-anesthetized or the opposite, will wake up in the middle of surgery. Monitoring vitals and anesthetic depth regularly allows you to use the minimal amount of gas anesthesia required. Your patient’s organs will thank you. With proper pain management, you can perform complex or invasive surgeries with less than one percent isoflurane. 5) Communication Agree with your nurses on what acceptable vital ranges are for each patient. Let them know when you should be notified of changes. It will do the patient no good if the numbers are being logged or stared at, with no intervention or change taking place when necessary. 6) Extubation Do not extubate prematurely. The “three swallows” rule is a widely spread myth amongst technicians and quite possibly doctors. The patient should show you they are conscious and fully capable of maintaining their airway. We should handle all patients as if they were brachycephalic during recovery from surgery. 7) Post-op Please don’t allow your nurses to believe their job is over once the patient is extubated. Most anesthetic deaths happen after surgery. Vitals should be taken every 10 to 15 minutes until they are normal and sustained. It is wise to continue monitoring every two to four hours to make sure there are no changes. A few suggestions: Even if the patient’s temperature was normal throughout the procedure, continue to monitor it Assess pain every one to two hours to make sure it is adequately controlled Offer small amounts of water, then food Provide TLC Document vitals and post-op care. Remember: In the eyes of the law, if it’s not in writing, it didn’t happen. Your records should include temperature, pulse, respiration (TPR) upon discharge Do not ignore the importance of having to eliminate. Few dogs will allow themselves to “go” in a cage. If a dog is whining or acting agitated, take them outside if they are able to walk. You may also want to consider expressing the bladder before anesthesia is over 8) Dysphoria Some canine patients can be very vocal during and after recovery. Educate your teammates so they know how to differentiate pain, attention-seeking, and dysphoria. Always assume a patient is painful. If pain is treated well and your patient is still vocal, you’re likely dealing with dysphoria (which may require sedation) or attention-seeking (which may resolve with TLC). 9) Patient pick up Don’t suggest a time that is convenient for you, and don’t let the client choose when it is best for them. Instead, use four criteria before deciding when to send patients home: they should be awake, aware, warm, and comfortable. 10) Discharge Don’t take anything for granted when it comes to clients’ knowledge. Educate them on the effects of anesthesia, such as tracheal irritation from the endotracheal tube or gastric upset from stress or medications. Make sure they know how to administer medications properly and at the right time. Teach them to how to assess pain and to differentiate it from dysphoria. Show them how to do physical therapy if needed. Make sure they understand incision care and the importance of the E-collar. Always leave the lines of communication open so the owner feels comfortable enough to call with any concerns. At a minimum, do a follow-up call the next day. Following these simple suggestions will benefit your clients, your patients, and your team. It is wise to remember and live by the mantra of Robert Smith, MD: “There are no safe anesthetic agents; there are no safe anesthetic procedures; there are only safe anesthetists.” HOW TO AFFORD ANESTHESIA OR SURGICAL EQUIPMENT Colleagues often tell me they can’t afford a new anesthesia monitor, capnography, or warming device. But are any of these things really that much out of reach? Let’s say you paid $1,000 for a handheld anesthesia monitor. Let’s also say you charge a mere $5 per use. Hardly a deal breaker for any procedure, right? And let’s say you use this new piece of equipment to monitor only one sedated or anesthetized patient each day, five days/week, 52 weeks/year. Examples include an ear flush, X-rays, or a bandage change under sedation. Would you agree this should be easy to accomplish once daily, over a year? If so, let’s do some simple math: Five procedures/week x 52 weeks x $5/patient = $1,300/year And remember, our theoretical piece of equipment costs $1,000. And you only charged $5 per patient. If you charged $10 per session, once daily, or if you did two sessions per day, at only $5, you would obviously make $2,600. Does that piece of equipment now sound like an expense or an investment? If you provide a valuable service that improves medical care, it is only fair to charge for it. Yet, you don’t have to charge a fortune in case you’re worried clients won’t be able to pay for better care. It’s not just good business, it’s also good medicine. Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified, is a board-certified veterinary surgeon and serial entrepreneur whose traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his website at DrPhilZeltzman.com. He also is cofounder of Veterinary Financial Summit, an online community and conference dedicated to personal and practice finance (vetfinancialsummit.com). AJ Debiasse, a technician in Blairstown, N.J., contributed to this article.
