By Kendra Freeman, DVM, MS, DACVS (large animal), DACVS (small animal)

Depending on your comfort level in the operating room, surgery can be fun and rewarding, or a major source of stress and anxiety. Much of the final outcome of a surgical procedure hinges on the success of the patient's recovery. Although setting yourself, your patient, and your client up for a successful surgical recovery can be challenging, it is important to identify and discuss the potential issues the recovery process may pose to clients and your patients.

The recovery process is so important. During a pre-surgical consultation I often tell clients, "What happens at home in the recovery period is just as important as what happens in the operating room." Communication is key to a successful recovery, especially once your patient leaves the hospital.

Clear communication about the pre- and post-procedure expectations is critical to the long-term outcome. Using a team approach before, during, and after the operating room can boost your success and client compliance. In order for this approach to work, it is important for the surgeon, the support staff, and the pet owner to understand the importance of their role on the care team. Below are some considerations for making the surgical recovery as smooth as possible.

Manage client expectations ahead of time

As they say, "An ounce of prevention is worth a pound of cure." Therefore, the pre-surgical consult is one of the most important steps in successful management of a post-operative patient. The pre-surgical consult is the time to set the stage with the client for expectations. It is also an excellent time for you, as the surgeon, to see how the client interacts with the patient.

By the time the client leaves this appointment, they should have a complete picture of the risks and benefits of the surgical procedure, but, more importantly, a detailed of understanding of what the recovery process will look like and what is expected of them as owners during the postoperative period including:

• What is the expected recovery time—one week? Four weeks? Eight weeks?
• How much activity restriction is needed during this time—small room confinement? Kennel and leash walks only?
• The dreaded E-collar. Just be honest with clients—nobody likes them, but they work! Other options are available, but make sure the one chosen is appropriate for the pet's recovery. The client needs to be aware that just because an option other than the E-collar is less stress-inducing for the client it may not work as well.
• Will the patient be in a bandage? If so, how often will it need to be changed and what costs will be incurred with each appointment? Emphasize the importance of activity restriction as appropriate for the procedure, as well as keeping the bandage clean and dry at all times! Managing bandage complications past the time when the original surgical site has healed is incredibly frustrating and adds additional costs to the client.
• How long will the patient be on medications? Will these be filled and provided at discharge or will the client need to have these ready to go when they pick up their pets? If necessary, provide a written prescription for medications to be fill at an outside pharmacy so the client can fill it ahead of time.
• What potential complications or setbacks in the recovery are common and what can be done to limit the potential for their occurrence?

Discuss all these considerations during the consult so the client knows what to expect during recovery and can make an educated decision about the procedure, and fully commit to their role in recovery. For example: for a dog not used to confinement, it may be beneficial to postpone an elective procedure requiring a prolonged strict recovery period until the client can set the patient up for success at home.

Minimizing surprises at discharge will go a long way with success. Clients can be overwhelmed by the amount of information provided at the consultation or pre-operative appointment. Therefore, providing written summaries of what they will be responsible for during recovery will allow them to prepare for their pets' post-surgical needs prior to the day of surgery. It will also allow them to review the recommendations and ask for clarifications prior to surgery or discharge from the hospital.

Setting the stage for a smooth in-hospital recovery

Consider a multi-modal approach to anesthesia, starting with pre-medications. Trazodone two hours prior to induction can decrease the MAC requirement of isoflurane. Gabapentin can help with relaxation, as well with minimal cardiovascular effects. Using a combination of appropriate medications for your patient and procedure can decrease the amount of each medication needed and limit potential side effects.

Although protocols can limit potential mistakes and calculation errors, make sure the combination of medications is tailored for an individual patient. Long, painful procedures or critically ill patients often benefit from multiple constant rate infusions which allow minimal use of gas anesthetics.

A calm, quiet recovery area is ideal to a smooth recovery from anesthesia. Frequent evaluation for pain, distress and/or dysphoria can help guide the need for additional medications in recovery. Preventing perioperative hypothermia can speed the anesthetic recovery process, which is the standard of care for human pediatric patients.

Managing discomfort during the recovery period is important. Additionally, distinguishing pain from dysphoria is key! A dysphoric patient misinterpreted as painful and given additional opioids can be unfortunate.

Homeward bound: Ensure success

Pharmacology to the rescue! Oral sedatives and anxiolytics can be beneficial once the patient is home, and they are reasonably easy to tailor to each patient. Trazodone is a good starting point to provide mild sedation and help with anxiety. It is readably available to be filled at most pharmacies with a wide dose range. Depending on patient temperament, acepromazine, gabapentin, and even clonidine can be added to aid in sedation and amenability to confinement.

Communication is key. Who at your hospital is responsible for discharging a surgical patient from the hospital? A well-trained technician is perfectly capable of this task. Ideally, this person should have some familiarity with the surgical procedure and recovery, and be able to anticipate common questions that clients ask during discharge.

Written instructions can help a client feel less overwhelmed, especially for cases with a prolonged recovery period.

Preschedule the recheck and or bandage change. Scheduling the recheck exam at the time of discharge is efficient for both your client and front office staff. Scheduling a follow-up phone call from a knowledgeable staff member several days into the recovery can help avoid emergencies. Your technician should be able to get a full update on recovery progress and answer questions the client may have now that the pet is home.

This follow-up also allows your team to assess if the sedation protocol sent home was appropriate for the patient or if adjustments are needed (i.e. is the patient still too active, or is it overly sedated?).

Who to contact if there is an issue? Even when you have done your best to anticipate questions and concerns, there will be inevitable questions once the patient is home. Make sure the client knows who to contact, what constitutes an emergency, etc.

Boredom busters. An extended recovery can be boring, especially for a young dog used to being active. Providing some environmental enrichment can help pass the time. Food-motivated patients may enjoy puzzle feeders or Kong-type treat dispensers.

If your patient can have some mobility, encourage the owner to work on basic obedience or even teaching the pet a few new (low-impact/energy) tricks! It will help both the client and the patient pass the time.

Clear communication before, during, and after the procedure can go a long way in managing client expectations and giving your patient the best chance at a smooth recovery. Use your knowledge of pharmacology for a smooth peri-anesthetic recovery, and to aid in recovery and rest once the pet is discharged from the hospital. Whether it is a simple procedure with a short recovery or a complicated orthopedic procedure with an extended recovery, surgery can be rewarding for both the veterinarian and the patient.

Kendra Freeman DVM, MS, DACVS (large animal), DACVS (small animal), is a graduate of Colorado State University and maintains dual certification with the American College of Veterinary Surgeons. She is an associate surgeon in Albuquerque, N.M. Her case load consists of orthopedics, general soft tissue, and sports medicine with the occasional return to her roots in large animal lameness and surgery.