Surgical Skills Lecture: Final Exam

When do we move the endotracheal tube?

when the animal is blinking and has swallowed 2-3 times

Why do we wait to remove the endotracheal tube?

To be sure that the animal is able to breathe on its own

* continue monitoring until alert and values return to normal
* start post op pain plan

What are exceptions for the normal timeline of removing the ET tube?

Brachycephalic patients

* wait as long as possible prior to extubation
* careful monitoring after extubation

What are acceptable methods for warming a patient?

heating units for lavage, iv fluids

microwave 1L for about 2-3 minutes

* shake up to avoid hot spots
* should be 98-99F

water circulating heating blankets

warm air (Bair Hugger)

water bottles

water-filled balloons or latex gloves

uncooked rice or lentils

What are unacceptable methods for warming a patient?

* electric heating blankets
* unattended Bair Huggers

What are the terms that describe post-op swelling?

What reversal agents are used in recovery?

Naloxone, Butorphanol

* reverses opioids such as hydromorphone, fentanyl, morphine

Flumazenil

* reverses diazepam, midazolam

Antisedan

* reverses Dexmedotomidine

Decubital ulcers

How do we prevent complications such as lung atelectasis or overflow of the bladder?

* propping the animal sternal
* \

Why should we untie the ET tube post-op?

for ease of extubation

Why may we only partially deflate the endotracheal cuff?

* regurgitation - vomit
* dental procedures - lavage/irrigation
* palatal or nasal procedures - bleeding

Look at the end of the ET tube after extubating. Why?

is it all there?

is there blood or regurgitation on tube?

* if any of these things are present, alert the doctor.

Postoperative monitoring:

Closely watch and document

* if you don’t write it down, it didn’t happen

Initial postoperative TPR

* repeat as indicated

Other monitoring may be necessary

* pulse oximetry
* ECG
* blood pressure

Possible post surgical complications:

* incisional complications
* hemorrhage
* hypoxemia/hypoventilation
* hypotension
* hypothermia
* hyperthermia
* emergence delirium
* cardiac arrhythmias
* hemorrhage
* uncontrolled pain
* prolonged recovery

Hypoxemia

decreased oxygen in blood tissues

What causes atelectasis?

often due to prolonged recumbency, can lead to hypoxemia

* propping animal sternal may help

What is the treatment for hypotension?

IV fluid bolus or rate increase

* crystalloids
* colloids

patient warming

pressors

* dopamine
* norepinephrine

What is the treatment/prevention for hyperthermia?

Evaluate potential causes:

* opioids in cats

Remove bedding

Fan

Alcohol on pads and ears

* avoid placing on surgical incision

Cool or room temp IV fluids

Offer water if alert enough to drink

May give antipyretic

What is classified as hyperthermia?

Temp >103.5F

What causes hyperthermia?

* emergence delirium
* in cats:
* ketamine
* opioids (hydromorphone)

Temperature >106F - at risk of cellular damage and death

What does emergence delirium look like?

* exaggerated uncontrolled movement
* paddling, thrashing, vocalizing

Opioid side effects:

* sensitive to loud noises
* sensitive to bright lights
* sedative/dysphoria

How is emergence delirium treated?

Make it stop

* approach slowly, comfort and possibly medicate
* tranquilizer

What are some reasons for arrhythmias?

* pain
* electrolyte abnormalities
* heart disease
* drugs

some, not all arrhythmias require treatment

What to do if superficial hemorrhage is noted?

* direct pressure 5-10 mins
* bandage if needed

What are indications of internal bleeding?

* pale mucous membranes
* rapid HR, RR
* abdominal distention
* swelling around surgical site
* hypotension
* shock

What are reasons that animals will bleed post-op?

* organ or vascular damage
* bleeding disorder
* bleeding vessel
* coagulation dysfunction
* platelet dysfunction

How to correct a bleeding vessel:

* go back in and fix it
* autotransfuse
* collect, filter and administer patient’s own blood
* transfusion
* blood bank
* blood donors
* colloids
* volume expansion

How to tell if there is uncontrolled pain?

Vital signs

* increased HR, RR, blood pressure

Vocalization, Restlessness

Depression

Painful on gentle manipulation of incision

Pain scores

> Differentiate from dysphoria/delirium

Prolonged recovery can be secondary to:

* hypotension
* hypothermia
* drugs
* decreased liver or kidney function may decrease clearance times of some drugs

if prolonged recovery is a concern, can reverse some drugs

What is dehiscence?

premature loss of sutures and opening of surgical site

* any or all layers
* can be serious and/or fatal

caused by licking, playing, rubbing, scratching, falling, infections, weak or inappropriate sutures

What is a seroma?

fluid pocket under the skin

* overactive patients post op
* deadspace from surgery

can delay healing

can lead to infection

keep patient quiet, warm pack several times a day +/- bandage

What if it is not a seroma?

may be an abscess, hematoma, or hernia

Infection:

* painful
* may have fever
* swollen, red, draining surgical site
* healing is delayed

May require surgical debridement

* remove contamination
* clean fresh edges
* culture and antibiotics

Who often writes discharge instructions?

Vet Techs

* the tech has been doing post-op care and recovery
* the tech has had more hands-on time with the patient

What should you tell the owners before surgery?

what to expect

* have a cage ready
* typical recovery period

tell them these things again once they schedule a pickup

tell them again at the pickup

AND send written discharge home

> all communications should be logged in record and a copy of discharges must be in record as well

Have everything waiting to go when the owner arrives:

* meds, collar, etc
* bill
* discharges

leave per in its cage, will distract owners

owner should pay before releasing the dog

talk TO the owner not at them or down to them

What information should be on the medication slip/bottle?

* name
* strength
* how many
* directions
* how much
* how often
* which route
* any specific drug directions
* empty stomach, not w/cheese, wash hands, keep refrigerated, etc
* why are they taking it
* potential side effects

What should you tell the owner regarding post-op care or issues they should watch out for?

* look at incision at least twice daily
* cold pack 2 days
* warm pack
* issure they are not licking or rubbing incision
* talk about what is healthy and what to look for
* at the time of discharge the incision…
* has minimal bruising
* appears healthy
* has serosanguinous discharge
* swelling, increased discharge, foul odor, bruising, opening up, sutures/staples removed early (count)

If there is discharge, tell the owner…

* when should it stop
* what does it look like now
* when to call

What to tell the owner if the sutures are absorbable?

* when can they bathe
* do they need a recheck on the incision
* normally take 10-14 days to absorb
* older patients take longer
* cushings or diabetics take longer

What to tell the owner about confinement…

* be VERY specific
* how confined
* for how long
* days
* weeks
* months
* until their next recheck
* why are we confining them

Cage rest/Bed rest

* Enough room to stand up, turn around and lay down
* Outside briefly on a leash
* Returned to cage confinement
* Don’t leave water in cage if bandage is in place

House confinement

* Can calmly walk around house when observed
* No stairs, no rough housing
* Outside on a leash for brief walks
* WhatReturned to cage when not directly supervised

What complications are associated with drains?

infection, contaminating house, dislodging prematurely

In casts, dirty, wet, slips, or any concern needs to be changed IMMEDIATELY. T/F?

True

* waiting 24 hours can make a small problem a HUGE one

What to tell the owner regarding a feeding tube…

* how long will it be in place
* how to clean it
* how to feed through it
* if the animal will have any food or medications by mouth as well as tube
* complications to look for
* make sure it is in place
* hasn’t been chewed off
* hasn’t migrated in or out
* mark with a sharpie or measure total length

Care needed for feeding tube…

* clean skin/tube area 1-2 times daily
* fresh bandage daily at skin
* may use dilute antiseptic around tube for cleaning
* may opt for clean, damp cloth for gentle cleaning
* tube should be bandaged to avoid dragging it or stepping on it or chewing it
* flush with water before and after each feeding

What drugs are used as appetite stimulants?

* low dose valium
* given IV usually in hospital
* cryoheptadine
* antihistamine
* steroids
* mirtazipine
* antidepressant

After a dental extraction, what is to be expected?

* may see faint blood in water bowl initially

rubbing or pawing at the face indicates pain

not wanting to eat indicates pain

foul odor indicates infection

mouth heals fast - 7 days

After a dental extraction:

give soft food for days to a week

* canned food
* wet their normal dry diet before feeding

no chew toys, rawhides, etc

* can’t chew on their own feet either

After gastrointestinal surgery, what should the owner watch out for?

watch for peritonitis

* depression, lethargy, nausea, vomiting
* swollen painful abdomen, increased bruising, fever
* 2-3 days post-op
* 7-10 days post if antibiotics are used

What should we tell owner’s to watch out for after perianal surgery?

watch for straining, vocalizing when defecating or posturing a lot without pooping

* pain
* stricture

After a cystotomy, what should we tell the owner to expect?

allow frequent potty trips

* avoid bladder distention
* bladder is inflamed so an animal feels urge often

monitor for straining to urinate or trouble getting a good stream

blood in urine is normal up to 36 hours

* should decrease in amount over time
* easier to see if pee on a white paper towel

of cannot urinate it is an EMERGENCY

* more than 24 hours is a really big deal

What to tell the owner to expect after an onychetomy…

no clay, clumping litter (dust, dirt = infection)

* use shredded paper towels, yesterday’s news, etc

crate confined

check toes for swelling, discharge, worsening or appearance of lameness

bleeding should be reported asap

cats need to be indoors for the rest of life

What to tell owners after an orthopedic surgery…

confinement

* what type, how long, why

leash walked, sling walked

* how often, how long

calorie restrictions during cage confinement

potential complications:

* implant failure, infection, not healing, lameness, etc

What to tell the owner to expect after aural hematoma or total ear ablation surgeries….

bandage care

* label ears in case owner or emergency vet has to remove

changing bandage

collar

medications

rechecks

eye drops for TECA if needed

What to tell the owners to expect after cesarian section…

keep separate until everyone is awake

* avoid crushing
* watch for aggression towards babies

discharge from hospital asap

* best place to get sick

weigh newborns once daily

* if not gaining weight, give extra time to private nurse
* still not gaining, give supplement

incision care is very important

vaginal discharge is normal

* red-brown
* few days
* no foul odor

normal loose stools

feed high calorie food, she should be pretty hungry

watch for red, swollen, or painful nipples

Pain medications

multimodal approach is best

preemptive analgesic is best

start NSAID before surgery

* not if GI upset
* not if bleeding disorder
* not if dehydrated
* don’t switch NSAIDs without a wash-out period
* NEVER with steroids

How painful is the animal?

1. Scratch
2. Skin incision
3. Muscle manipulation or spay
4. dental extraction
5. joint surgery
6. fracture

1 being low potential for pain, 6 being a big deal

What the owner needs to hear…

* Three things
* Discharges should have the details
* Repeat, repeat, repeat the three biggest

things

* Always make it clear when they need to come back
* Come back early if problems
* Potential complications
* How to get a hold of someone, especiallyat night or weekends

What is lung atelectasis?

\
the lung collapses due to:

* pressure
* weight

can’t oxygenate well

takes 6-12 hours to reinflate, or longer

can occur in a few hours

How do we compensate for or prevent lung atelectasis?

* flip sides
* sternal
* listen
* coppage
* “walk”

What are decubital ulcers caused by?

reduced blood supply to skin when in the same position for an extended period of time

laying on boney prominences

dragging self around and damaging a boney area

* friction
* shear

What are likely spots to develop decubital ulcers?

* areas without substantial padding
* hips
* elbows
* ischiatic tuberosity
* tail bone
* hock
* lateral
* calcaneus

Stages of bed sores (decubital ulcers): Stage 1

red skin

* can go away shortly after pressure is relieved

Stages of bed sores (decubital ulcers): Stage 2

partial dermal skin loss

* ulcer or blister
* if treated quickly can heal fairly quickly

Stages of bed sores (decubital ulcers): Stage 3

full skin loss

* deep crater-like wound

Stages of bed sores (decubital ulcers): Stage 4

large scale loss of skin with damage to muscle, bone may be exposed

* most serious
* these can be fatal due to infection

How to recognize decubital ulcers:

* skin discoloration
* warmer temperature than surrounding skin
* can penetrate muscle, even to bone
* catching early is key to success

How are bed sores treated?

* relieve pressure
* treat the sore
* clean
* dry
* cover with a bandage
* improve nutrition
* and other conditions to help healing
* surgery to move healthy skin to cover
* analgesia
* antibiotics
* may take 2-4 weeks to see signs of healing
* prevention is the best treatment!

lower motor neuron bladder

Urine Scalding prevention:

urinary catheter

* high risk of maintenance
* risk of infection is great

diaper

* doggie
* modified infant

bathe frequently

* use pet shampoos to avoid pH issues
* dry after baths

‘spot’ cleaning

* personal cleanser
* dry baths

power

* baby power
* medicated gold bond

What are the benefits of rehabilitation?

* increased blood flow
* reduced inflammation/edema
* reduced muscle atrophy
* helps to retrain muscles
* pain control
* reduced periarticular contracture
* may promote fracture healing

Who are candidates for rehabilitation?

* orthopedic conditions (CCL rupture, fractures)
* neurologic conditions (IVDD, DM)
* arthritic patients
* agility dogs

What is electrical stimulation?

this is applied by an electrical stimulator that transmits a current from one electrode to another in a specific area of the body. By setting the waveform, frequency, duty cycle, and intensity parameters one can achieve a desired function and purpose.

Waveform:

the shape of the visual representation of pulse current on current/time plot to voltage/time plot

Pulse rate or frequency:

the rate of oscillation in cycles per second, expressed as pulses/sec (pas) or hertz (Hz)

Duty Cycle:

the amount of time the stimulator is delivery current compared with the rest period between contractions, usually measured in seconds

Ramp:

the time in seconds from when the current begins to the peak current

Interferential:

waveforms work at a higher frequency and are able to address chronic, post-surgical and post-trauma acute pain in patients

Premodulated:

waveforms use a single channel is used to mix the frequencies prior to delivery of the current through the electrode to the body and is effective in treating smaller muscle groups, joints and injuries closer to the skin

Russian:

the russian current waveform is a type of electrical stimulation that delivers medium frequency current in alternating pulses or bursts of energy and is effective in reducing pain as well as increasing muscular strength.

High voltage pulsed current (HVPC):

high voltage current is able to achieve deeper tissue penetration making it effective in facilitating wound healing and relieving muscle spasms

What nerves do TENS target?

TENS specifically target the sensory nerves, which are responsible for sending pain signals to the brain

What do NMES target?

NMES targets the muscle itself, specifically through the motor nerves

* this allows the NMES machine to create a muscle condition to recruit more muscle fibers when training; warming up or recovering.

What are the contraindications of electrical stimulation?

* high-intensity stimulation directly over the heart
* pacemakers
* seizure disorders
* areas of thrombosis or thrombophlebitis
* infected areas
* neoplasms
* pregnancy

What are the precautions associated with electrical stimulation?

* areas with impaired sensation
* skin irritation or damage
* near electronic sensing devices such as ECG monitors (possible interference)

What is the time in seconds from when the current begins to the peak current?

Ramp

When using e-stim for pain management the goal is to depolarize __________ _____________ to ___________ ______________.

Neuromuscular electrical stimulators recruit _______ first, then ________, which is the reverse of the muscle recruitment pattern in a conscious physical contraction.

Why do we use electrical stimulation?

What is the difference between TENS AND NMES?

TENS specifically targets the sensory nerves, which are responsible for sending pain signals to the brain.

NMES targets the muscle itself, specifically through the motor nerves.

What is the term “laser” an acronym for?

Light Amplifications by Stimulated Emission of Radiation

Laser Therapy terms:

* low-level laser
* low-intensity laser therapy
* cold laser therapy/hot laser therapy
* soft laser therapy
* low-power laser therapy
* light therapy
* phototherapy
* biostimulation laser therapy
* class 3 laser therapy
* class 4 laser therapy
* high-power laser therapy
* red light therapy

The application of electromagnetic radiation within the red and infrared spectrum over injuries and lesions to stimulate healing and provide pain relief within those tissues is 

PHOTOBIOMODULATION

Process of Laser Therapy:

1. light photons penetrates to skin
2. cell’s chromosomes absorb photons, alerting cell membranes
3. production of ATP, beta endorphins, and serotonins
4. pain relief and cell healing

Safety precautions associated with laser therapy:

* protective eyewear should always be used
* never direct laser treatment into the eye
* use caution with beam reflection on metal surfaces

What are the contraindications associated with laser therapy?

* pregnancy
* open fontanels
* growth plates of premature animals
* malignancies
* dark colored skin, dark coats
* infection

When should an incision be warm-packed?

warm pack for 3-7 days

* help comfort and healing
* 3-5 times daily if possible
* increase in frequency if serum forms