So hello. And welcome to, this webinar and this is anaesthesia compass navigating the path from pre op to post op in feline and canine patients. So basically, we're gonna be looking at a few different cases, a few different, breeds and then just running from the pre op period right through to the recovery, and we're gonna be touching on, the emergency care of these patients as well.
So just a quick intro to myself. My name is Rebecca. I qualified from my school college in 2017 as an RVN.
I've since done my certificate in emergency and critical care and my advanced veterinary nursing certificate in anaesthesia. And I'm currently, working towards my master's degree in anaesthesia as well. I currently lo and I teach part time at my school college stop.
So we've got quite a few learning objectives for today. So our first one is information taken during the admin appointment. We're then gonna touch on patient fasting.
Just because not every patient should be fasted in the same way prior to anaesthesia, we're gonna be looking at our pre op assessments and what, we need to do during these, we're gonna be looking at our species and procedure specific con, considerations. The RVNS role within anaesthesia. So the monitoring of anaesthesia getting the patient ready and what not We're gonna be looking at our equipment safety checks.
So this is just mainly our anaesthetic machine and our circuits, and then our setup of our multi parameter. We're then gonna be looking at the normals and abnormals of what we see on the multi parameter. So our EC GPO two blood pressure, and Cappy and then we're gonna be touching on the plan for recovery.
And, just a brief on preparing for emergencies and who's more likely to fall into emergency in recovery. So as we know, our admit appointments play a really crucial role within, veterinary anaesthesia. Usually these appointments are nurse led.
So during, these appointments and consultations, we should be gaining as much important information as possible. Which will then help us further into the plan for anaesthesia? It will help us plan, prepare and organise for our patients.
Just, because we're asking so many different questions to the owners. It means we can go through things such as feeding, vomiting, diarrhoea, any medical conditions and what not. So what we should consider, so we should ask and discuss any existing medical conditions that might not be noted on the patient's file.
This is more so for, like, new clients or younger patients who have not got much of a medical history. And this is just because conditions like diabetes, heart disease, epilepsy, pancreatitis, chronic kidney disease, liver disease, can sort of significantly significantly impact our anaesthesia. So we should also be discussing alongside this any medications that the patient may be on.
So this would be any sort of non RT medications. Such as any anti inflammatories, an antibiotic course. Any steroids, anything like that, medications, for our conditions, such as diabetes, like insulin.
We need to be very careful when we're anaesthetizing These patients, we need to make sure that we're giving doses correctly. So as in when the owner usually gives this at home just so that we can keep in sync with the the owner plan, and that we're not sort of, causing any, like hypo or hyper or anything like that. And the other thing with insulin as well.
We might need to be checking this quite. We might might need to be checking the blood glucose quite regular through the patient's sta. So, normally, during anaesthesia, we would check pre op, and then we'd probably do, like 30 minute intervals during the anaesthetic, and then we would be checking every hour to hour and a half in recovery.
We would also want to be asking at this point about any allergies to any medications. So sometimes, when we ask this question, the owner's initial reaction is to discuss things like food allergies and skin allergies. So the food aspect is really good for us, just for our, feeding post op.
So if we have got a patient that's allergic to chicken, for example, it's good to know this, just so that we're not given anything that could sort of cause cause an allergic reaction, delay, any recoveries, anything like that. But more so for the allergies. We're focusing on, any allergies to things like non steroidals.
Any adverse reactions that the patient may have had in the past, so this can be things like vomiting and diarrhoea. And this sometimes is not always associated, with the er as a reaction or an allergy. But we should try and make this as clear as possible, during our admit appointment, and allow the under the owner to understand the differences between what is an allergic reaction and what's an adverse reaction.
We should also be asking about any recent vomiting or diarrhoea. So normally, with anaesthesia, we don't really like to anaesthetize patients that have had recent vomiting or diarrhoea unless it's an emergency. And this is just usually so that just because it heightens the risk of regurgitation, vomiting and then also adverse reactions through drugs that we use during anaesthesia as well.
So what I tend to do in my admits appointments is just explain this to the owner and just say, within the past 48 hours, has your pet pet vomited or had any diarrhoea? If it's just a case of this one episode of vomit and it's just like a stress vomit, that's absolutely fine. But if we're, hearing that we've had, like, a few days of diarrhoea or we've had, like, a bit of a a day of vomiting, and they've not been quite been themselves.
Then that's where I try and get the vet to come into the admit and just do a health check on them. We would also be asking about any previous anaesthetics. So this would be, just to make sure that the protocols that we've used in the past is is suitable for the patient this time.
So a lot of the time we use things quite commonly, such as metamed and, methadone. So if we have had, sort of an, an event during a previous anaesthetic with these drugs so it might be an arrhythmia. They could be severe bradycardia.
They could be vomiting with the opioids. We need to be making sure that we ask the owners about this because ideally, we would tell owners if there was any problems like this. And this is just so that we can adjust the anaesthetic plan as and when we need to.
We would also discuss, and consider our age. So different life stages will sort of tolerate anaesthesia in different ways. So our elderly patients, because they're more prone to having sort of, like predisposed heart or respiratory conditions, we might want to consider, using an alternative.
If And an alpha two. We might want to consider using sort of like a benzodiazepine like me midazolam just because it has less cardiovascular effects and then with our species and breed. So again, with, when we're talking about cats and dogs, one of the most common things that we would use during anaesthesia is paracetamol.
And as we know, cats can't have this because it is it's toxic. So we want we want to be asking, or sort of identifying, because we can do this visual aid, the species of the patient, and then asking about the the breed as well. Usually, the concern I have with the breeds is any brachycephalic breeds.
I don't wanna be sort of planning with the surgeon. Any respiratory depressive drugs? Just because that will sort of heighten the risk for, sort of like, respiratory distress or, an apnea episode or anything like that.
So our pre op fasting. So in regards to pre op fasting, we should always look at our patients as individuals. We should be doing this through all of our anaesthesia as well.
So this means that fasting times might vary on several different things. And this includes, our life stages our medical conditions. Any medications?
The surgical procedure itself and our breed species and emergencies as well. So how does pre op fasting? How do we How do we pre op fast, Appropriately, as opposed to blanket fasting.
And how does this help our patients? So pre op fasting appropriately to each individual helps to reduce the risk of aspiration. It ALS also lowers, gastrointestinal complications.
And it also prevents dehydration, and it helps us to manage their metabolism as well. So with our healthy patients, we are OK, so these studies to show that we're ok, to fast them for, sort of 4 to 6 hours. However, we are seeing well, I see quite commonly in practise where pa all patients have been starved for sometimes 12 hours at a time.
And this is regardless of their age, the sort of breed and the the procedure as well. And the problem with this is, there is studies to show that fasting for such a long period of time can actually increase the risk of, gastrointestinal reflux. And this is just because the stomach is so empty and it's contracting so much because it's so empty it can actually, cause a build up of acid, which can then be re regurgitated.
So if we're fasting for, up to 4 to 6 hours, it can actually reduce the risk of gastroesophageal reflux. Whereas patients that in the study the patients that have been fasted for 8 to 12 hours tend to show more symptoms of this. And like I said, this is just more so because of the the increased stomach acidity.
So with our neonate and our young patients or patients under eight weeks of age, as well as our severe diabetic patients, we shouldn't really not be fasting these for longer than 1 to 2 hours. And this is just so that we're not causing severe sort of blood glucose fluctuations. So if we have got a really young patient, and we're fasting them for eight hours.
Then the blood glucose is essentially just gonna go straight through the floor, which is gonna cause us a lot of issues under anaesthesia. And then, obviously, our diabetic patients, we need to be making sure that we're not fasting them for long periods of time. And they're going without their insulin for long periods of time with the diabetic patients.
What I would tend to do is, like I said before, is get a baseline, blood glucose. So I'd probably ask the owner to do one before they bring them in. I do one in, the admit appointment.
And then we do a series during the anaesthesia as well with our patients who have, regurgitation history. So this can be our brachycephalic patients. It can be our sort of prone, G I upset breeds.
So, like your Labradors and your obese breeds as well. It is recommended, through the findings of the, the study that I've looked at, that we should be fasting these patients for no longer than 4 to 6 hours, and we should be giving them, AAA meal sort of like up to six hours prior to the anaesthetic of about 10 to 25% of the usual amounts. So when If if we are sort of saying normally start from 10 p.m.
We can start from 10 p.m. Or we could start from midnight, and then we could give, say, a little, meatball of food at around 6 a.m.
And then that means when we're coming in for anaesthetic, we're probably not going to be starting, the up until around 1011 o'clock. It means then the stomach's not too empty. We've got a lining, and we've also fasted them for a period of time as well.
So with in terms of, managing our metabolic balance is, prolonged fasting can actually lead to metabolic imbalances. Such as hyperglycemia. Like I said, this is more common in our small animals or patients with medical conditions.
So adjusting these times can help us maintain a stable blood glucose level. And this is just critical for the patient's safety under anaesthesia. It also helps us to prevent dehydration.
So obviously we're getting water from food. And I hear it quite commonly where owners have taken away the water for 10 to 12 hours. So what I normally say is they can have water down overnight, but then at about 67 o'clock in the morning if they just pick that up, and this just means that we're not seeing on the blood signs of dehydration.
We're not having to over supplement with fluids. And we're not having to sort of do extra series, of pre op tests, to try and find the cause of dehydration. If it's a case of the onus taking taking away the water, then we can pretty much understand that.
That's why we're seeing sort of red flags on our, pre-op parameters. So planning, for our patients and considerations that we need to be thinking about so before anaesthesia, we should be considering the needs of our patients. Such as our life stage, our breeds and the pre procedure is it itself and how this can affect our anaesthetic.
So when we're planning the anaesthetic protocol, we should be considering our a S a grade. And this is just, because obviously the the higher the a S a grade, the higher the risk of complication. We should be considering our location of surgery.
So if we're doing, for example, thoracic surgery, we might be needing to, give assistance with ventilation. We might be needing to I am sort of, give assistance in recovery with ventilation and monitoring of respiration. With our, abdominal, surgeries.
We might need to sort of, support the stomach. We might need to empty the stomach during the anaesthetic. So we can do this with, like, nasal gastric tubes.
And we might even need to be considering the risk of bleeding as well. In recovery. With our analgesic plans, we should be considering our painful surgeries.
So for our, for example, our orthopaedic surgeries or, stitch ups after traumatic events. We need to be, sort of offering the multimodal approach, to our patients. So making sure that they're immobilised.
They're unconscious, and they do have the adequate an analgesia as well. We also should be considering surgical time. So if we have got quite a lengthy procedure, and we've got a big cavity open, such as the ab abdomen.
Then we should be considering the temperature during these longer procedures. And we should be looking at interventions we can put in place to to maintain the temperature. And we stop it from, falling into, sort of hypothermic ranges.
We should also be, considering the breed. So our brachycephalic breeds as we know, they've got a high risk of regurgitation. So we need to be planning for that.
What, sort of preventative treatment. Can we give beforehand? What can we do in recovery?
To reduce the risk of of, regurgitation as well? We need to also be looking at species. So, like I said before, about the, about cats with paracetamol, and then also with lidocaine as well.
If we're doing CRIS, we need to be very careful. When using CRIS in cats. And we need to be very careful when, planning for the analgesic protocols as well with our life stages, we should be looking at, for example, our paediatric versus geriatrics.
What are the differences between these patients and what can we be expecting? So, with our paediatric patients, we usually have more underdeveloped renal and hepatic systems. Meaning drug metabolism, is is sort of, much more delayed, meaning that the effects of the drugs are gonna be there for much longer.
And then with our geriatric patients, Like I said before, they are more prone to, cardiovascular disease. So do we want to be using, sort of high doses of, alpha twos, or do we want to be using lower doses and topping up when needed? Do we want to be, sort of repeatedly checking the ECG for arrhythmias?
Blood pressure monitoring throughout the stay. So these are just all things that we should be considering, for our different species procedures and breeds as well. So the surgical procedure and an and An and our anaesthesia.
So when outlining considerations to think about during our planning for anaesthesia, we should identify the type or location of the procedure and how this can impact our patients under G a and how we monitor them and how they can recover as well. So our duration of surgery so this can impact our blood pressure, our temperature, and our healing and recovery times. So we do want to be making sure that if we have are expecting a long procedure, so if we're doing orthopaedic surgery if we're doing, ex lapse cyst is things like that, then we want to be making sure that we have got temperature maintenance, equipment in place.
So this can be heat pads, bear hugger, your hot hands, all them sort of things. We want to be making sure that we've got, a nice, clean environment to just reduce the risk of infection. Because, obviously, with our delay with our prolonged surgery, it can actually influence healing times as well.
We also want to be keeping a close eye on our blood pressure. So if we have got, quite a prolonged surgery, we wanna be making sure that we've got fluid therapy on hand. So whether they're already on this or it's a case of they are, we've got these on the side, just in case our blood pressure does drop.
Then we wanna be be making sure that we've got these in place. We've got things such as blood products. If we need to replace any losses and this will just help for a more sort of stable, organised, less stressful anaesthetic.
If we're having a quite a prolonged, surgical time, we should be looking at our invasiveness of the procedure as well. So our minimal, our our minimal versus invasive surgery. So our minimal surgery is, sort of just like, like, a sort of subcut sort of stitch up.
So it might just be a little wound or something from a fence, whereas our invasive procedures is like I said before, our abdominal surgeries, bitch phase are classed as invasive surgeries. Any of our soft tissue surgery? Even some of our orthopaedic surgeries as well, because we're going into a joint capsule.
So we wanna be, expecting with invasive procedures that we can have, fluid loss, whether that's in the form, of blood or actual fluid itself. We wanna be making sure that we've got extensive monitoring in place, so fluid therapy and blood products to sort of maintain homeostasis, whereas our non invasive procedures like our small stitch ups or even scales and polishes, they have a much sort of lower risk. But we still need to be careful when managing these patients under anaesthesia.
With our risk of bleeding, we wanna be considering how much, when is the sort of time where we'd be expecting bleeding and do we have any interventions in place? So again, referring to abdominal surgery, we would sort of be wanting to expect some bleeding. But not anything ex excessive.
But we we need to be making sure that we have procedures in place and intervention in place for those, excessive bleeds as well. So what I tend to do is discuss with the surgeon points in which they feel, the the the surgery is at higher risk, or the patient is at a higher risk. And then I sort of try and make a note of this, and then they try and communicate with me when they're starting this point so that I can just sort of, make sure that I'm double checking absolutely everything on parameters, our position of our patient as well.
This can impact our anaesthetic. So if we're we've got sort of an obese dog, for example, on the back for a long time. So if you've got sort of a larger breed for a bit spare, then essentially, if we're not positioning these patients correctly, then we can actually be, sort of impacting our respiration ventilation and also, pain as well.
If our chest is sort of pushed against the cradle, that's just not quite big enough for the patient. And essentially, the lungs can't expand enough. And then if we're sort of not putting any pads or anything under the hips this is more so for our, obese patients and elderly patients.
Then essentially, they're gonna be waking up feeling quite painful because the hips have been on sort of a hard table for a couple of hours or so. So we need to be making sure that we've got an analgesic plan in place and that we we we can sort of go and do pain assessments afterwards just to make sure that, these patients are nice and comfortable. So our a S a grading.
So we should be grading all of our patients regardless of their age, the species, the procedure and the length of the procedure. Our A S a grading, is a critical tool that's used to assess the health status of a veterinary patient before anaesthesia or surgery. The the sort of classification, helps us in predicting any surgical or anaesthetic risks and any potential comp complications.
Which means that we can sort of, promote better preparation and management of our anaesthetic cases. So as we know, our A S, a one is our normal and healthy patients. Our A S a two is our mild to moderate systemic disease.
So these are like your brachy patients. Our a S a three is our severe systemic disease. But it's still sort of active.
So they're still sort of living a decent life. Our A S a four is severe systemic disease and incapacitated. So this is where the systemic disease is actually gonna be causing severe problems for us, and then our a S a five is our terminally ill or, sort of critical emergency patients where if we don't perform surgery, then they are gonna die, and then we should be adding E next to any of these grades that we think is an emergency.
So usually a S a one. We wouldn't be putting a knee next to this. Anything from two upwards.
Really? So the a S a grading? The scale is based on the patient's overall health.
It allows us to identify if we need to do any further work up before anaesthesia, and it promotes good communication with the team and the owners. So if we are seeing a patient and we're going, yeah, they're in a S a three. That means we can communicate with our other team members and they So if if we've got a, sort of recovery team, we can communicate that this patient is in a S a three, meaning that they could have more more risk during recovery.
And we can also, pass over a recovery plan and get them to monitor, as in how how they would need to. It also helps us communicate better with owners owners as well. So normally in admit appointments, I would say that any patient is as much risk under anaesthesia.
But if we are sort of grading these patients and giving examples as to why they graded as that, then we can go to owners and say, Well, your patient is an A S a grade three because they have, of a a mild kidney disease. So there is going to be a higher risk so we could offer more, things to these patients if we're offering fluids. We could say to your owners, we want to be offering fluids.
This will be an extra cost, but this is because of this. So our surgical safety checklists, So again, these are really important during our anaesthesia. And these allow us to ensure patient safety during the procedure and during the full, sort of anaesthetic period as well.
They provide a step by step protocol that helps us minimise risks prevent our errors. And they should be used regardless of the patients. Sorry, the procedures length or invasiveness.
So if we're just doing sedate clip nails, we should still be doing a checklist. If we're doing, sort of like emergency surgery, then we should still be doing a checklist. It just makes sure that it helps us to make sure that we've covered all bases with this patient and then it also helps us plan.
Our recovery is much better as well. So on the screen, the checklist that I use is this one, and it's got our pre induction. So usually our, sort of like equipment checks.
It's got the preprocedure. So before incision, it's got our anaesthesia, so into anaesthesia. And then it's got our post op and recovery plan as well.
And that just means when I've completed this because I write all over it, I would send this to, sort of the recovery nurses or ward nurses, and they can see exactly what's going on with this patient. And then I would also be writing the plan on there as well. Yeah.
So pre oxygenation before anaesthesia. So we should be aiming to pre oxygenate all of our, patients prior to anaesthesia and sedation. And this should be really before any medication is administered.
So we should be aiming for about 3 to 5 minutes of pre oxygenation, and then we should continue this when premeds have been given as well. So sometimes with our patients. If we've got quite a stressy patient and then sometimes trying to give oxygen, can actually cause them more stress than it's worth.
So there is a few different ways that we can pre oxygenate. So with our more stressed patients, I would personally try and oxygenate them in an oxygen cage if it's possible. Whereas with our patients who are just quite happy to sit there, sort of chill out with you have a little stroke and stuff, Then I would be using things such as flow by, a face mask, even nasal prongs as well.
So there is, like, quite a lot of benefits, to these things, these ways of delivering oxygen. But there is a few, sort of cons to them as well. So with our face mask, ideally, we don't want to be delivering oxygen, to brachycephalic patients in this way.
And this is just because the mask itself can sort of put pressure around the eyes, and it can damage the eyes. It can also sort of make them feel quite claustrophobic with them having such a narrow, flat face. Then if we're putting something in front of them, then that can make them feel quite claustrophobic, which will then increase stress our oxygen cage.
So if we have got a really really stressed patient and a larger breed and one that might be slightly overweight as well, then if we've not got that cage, temperature controlled, then we shouldn't be placing them in there. Because within a couple of minutes, that cage can go from sort of normal room temperature to, sort of like severe temperatures that can cause hypothermia, heat, stroke, anything like that with our nasal prongs. So if we have got patients, that are having any sort of airway surgery, or we've got patients that have got quite sort of small airways, on nerves such as our paediatric patients.
Then essentially, if we're putting nasal prongs up there, we can actually damage them, nostrils, and we can quite cause quite a bit of pain as well. So we need to be quite careful when we're using nasal prongs in any small patients and then with our floor by, so this doesn't always deliver a great amount of oxygen, But if we have got quite a stressed patient, a small patient that we can't place nasal prongs on. Then giving floor by is better than giving no oxygen at all.
So the main benefits of pre oxygenation before anaesthesia is it reduces, hypoxemia. It helps us to maintain and increase. The partial pressure, and it also helps to reduce desaturation during apnea.
So with our, veterinary patients, they usually fall into respiratory arrest before cardiopulmonary arrest. And this is just because they have less sort of oxygen store reserves. So if we are using, sort of respiratory depressant drugs during anaesthesia such as propofol, on induction, then essentially, if when we are.
If we are preoxygenated before this, then we're reducing the risk of our, SPO two from desaturating during the apnea. Initial phase. So now we should be moving on to selecting the correct breathing system.
So the breathing system is crucial, as we know during anaesthesia. It allows us to maintain anaesthesia. It allows us to deliver it more effectively and safely as well.
And as we all know, the choice of circuit depends on multiple factors. Such as the patient size, the procedure and the surgical time as well. The two main categories of circuit circuits used are rereading and non reb breathing.
So our rereading circuit is usually our circle and our AD a so these are quite expensive to set up. But I prefer these under, using these for anaesthetics. Just because I personally find the anaesthetic is much more stable.
We can provide IP PV. They allow for good, sort of heat exchange as well. But the downside is, we've got to be checking soda line.
If we're not on with checking that, then, we can cause problems with capnograph and ET CO2 as well. And non reb breathing circuits. These are things such as your lack, your mini lack, your T piece and your burn.
So I prefer to use T pieces and burns. Just because we can offer IP PV with these, whereas our Mini Lac and our lack aren't the greatest to be U, using if you need to be given, sort of quite long cycles of IP PV. So if we've got for example.
Thoracic surgery and we don't have a mechanical ventilator. Then I wouldn't personally be using a mini lack or a lack. I would rather use the T piece of the bin just because I can provide it IP PV much better.
So leak testing our circuit. So as part of our equipment checks on our surgical safety checklist, we should be making sure that we're leak testing our circuits. Just to identify that they're ready for use, they're safe for the patient.
And they're also safe for the environment as well. If we are not leak testing our circuits, then potentially we can sort of be causing a lot of harm to ourselves and our colleagues. So there is There has been, like, reports in the past where, like this is a long time ago where circuits have not been leak tested scavenging has not been checked, and people more so pregnant women in practises have actually have miscarriages due to, the gas leaking into the environment.
So we need to be very, very careful when we're, selecting our circuits and setting up our machines. We should always be leak testing Even if we've used that specific circuit all day, I leak test between every single procedure. This is just because the amount of times we're moving it moving the circuit around potentially, we could cause a crack we could cause a kink.
Things can get detached without us knowing. So I always just make sure that I'm checking it after every single procedure. So when we're check Leak testing our leak testing the circuit, we should be attaching the selected circuits the input valve of the anaesthetic machine and just ensuring that this isn't loose.
We should then be turning our a PL valve of the circuit to the right, using our, a cap to cover the end of the circuit which attaches the patient so that on the picture, the cap is the red thing on the end where the patient attaches and then that a PL valve is just above the bag. With the blue dial, we should then be attaching, the scavenging. So whether this is, piped into the wall or a floor resorb, if it's a floor resorb, we should be weighing this beforehand.
And in between every procedure just to make sure it's not exhausted, we should then be turning the oxygen floor on by using the dial, ensuring that the bag slowly fills and the bobbing continues spinning and isn't fluctuate fluctuating. We should then turn off the oxygen and use the oxygen flush to fill the bag. This allows us to make sure that our oxygen flush is working.
We should fill this so it's fully inflated and we should monitor for deflation. Early squeaks, for around 10 seconds or so, and then we should turn the a PL valve fully to the left and remove the cap. And we will now say that this circuit is now ready for use.
So our anaesthetic machine safety checks so again alongside our, circuit checks, we should be checking our anaesthetic machine before, the first anaesthetic and in between every anaesthetic after that. And then also, as the last sort of thing we do before cleaning it at the end of the day. So to do this, we should be ensuring that the cylinder, the oxygen cylinder is switched on.
We should check. Check the tank gauge, for the levels of oxygen within the cylinder. So if this is below a third, then I tend to just notify, people around me and just say oxygen is a little bit low.
If we've gotten a lot of anaesthetics in today, then if I'm on anaesthesia, then can sort of like the prep nurses. Just be aware for the alarm, so that they can go and change it if it does run out. So we should be first turning on the oxygen floor with the dial, ensuring the bobbin isn't rotating.
And it is so sorry. Ensuring the bobbin is rotating and it isn't fluctuating as it as it reaches the top. We should locate the 02 flush button, ensuring this works.
We should also be visually checking the inhaling levels on the chamber. And we should then be turning off our oxygen and, sort of twisting dial on the inhaling gas just to make sure that the dial works properly. It clicks into place.
And it's sort of not, too loose or anything like that. Once we've done this, we should be visually inspecting the machine for any damage, any rust or any missing parts after we've done this. And we're happy then that we can say that anaesthetic machine is now ready for use.
So I'm monitoring of anaesthesia. So as RVNS, one of our main roles and skills is the monitoring of the anaesthetic. So, when we're monitoring the anaesthetic, we one of our main jobs as well, is to be ensuring patient safety.
During this period. There's lots of different ways we can monitor anaesthesia and lots of different techniques which, which provide us with, critical information regarding the patient's health under the anaesthetic. And this allows us to sort of adapt our techniques and promote more stable and safe anaesthesia as well.
So at this point, we're gonna be looking at our hands on monitoring a multi parameter monitoring. And this will include cat grey, SPO two, blood pressure and ECG as well. So our hands on monitoring.
So this is something we should be doing regardless, of what? Monitoring equipment. We have the procedure, the patient and the case.
So this involves regular and sort of systemic, S. Sorry. Systematic checks of the patient's vital signs, and anaesthetic depth using a basic and non invasive technique.
So this approach of hands on monitoring it complements our sort of multi parameter monitoring. And it allows us to check for, like any changes in the patient's condition, which then allows us to sort of put in interventions in place. So what we should be doing with hands on monitoring is first article taking the chest.
As we're doing this, we should be palpating pulses for any pulse deficits. We should be recording our respiratory rate. By looking at the bag moving or the patient's chest, we should be recording the temperature.
So whether that's rectal oesophageal, you can do up the nose as well, and we should be assessing our mucus membrane, colour and capillary refill time as well. So when we're doing the cycles of this, there should be no pause in between. Once we've got from auscultating the chest through to, assessing the capillary refill time, we should then be repeating the cycle over and over, so it should just be continuous throughout.
It shouldn't be where the patient is left for five minutes without us, sort of not necessarily recording something, but listening to something. It should be a continuous cycle throughout. So our multi parameter set up.
So during our anaesthesia, we use multi parameter to monitor the sev several different things. At once, including the heart rate and rhythm, the respiration, blood pressure, SPO two and temperature. So we use this alongside our hands on monitoring and when we're using this equipment, we should be making sure that it's settle correctly and that we're able to troubleshoot for any problems as well.
So before we're connecting this to the patient, we should be making sure that all the leads are attached and untangled. This just makes it easier to see which lead goes to what, and it just makes for a safer environment as well. When we're setting up the ECG, we should be setting this to lead to and on the surgical setting.
We should be set setting the scale of the ECG. So the desired speed. So this is how many sort of complexes you want to see in a given time.
So this can be 1525 or 50. I normally like to set it at 25 just because it means I can see a good variety of complexes and quite clear as well. When we're setting the SPO two, we should set the scale of this, to the same as the ECG.
So this means that it's running at the same speed as the ECG. And this is just because we need to be seeing, a pulse speed for every QR S complex. If we're seeing a QR S and then a pulse speed separate to this, then this would suggest the pulse deficit.
So this is where our hands on monitoring will sort of confirm this. Our capnograph should then be set to measure. We should be making sure that the ranges are all set up.
So it's usually between 35 and 45 and our blood pressure, we should be correct, selecting the correct size, blood pressure cuff. And we should also, if we if our machines allow us to set the machine to the correct cuff size. And this is just because if we're on a dog setting, but we've we're, monitoring a cat, then essentially the the pressure on the cloth will not inflate.
What it as much as it needs to, and it can actually just give us sort of false readings. So I always just like to make sure that if I'm monitoring a cat, it's on cat. If I'm monitoring a dog, it's own dog.
And then sometimes you can put in the weight as well, which also helps. So I just put in the weight. And that just means that the pressure is set to the correct amount.
So at ECG. So whatever normals that we're looking for, so a normal ECG should consist of a clear P QR S complex. Complexes should be S similar in terms of height and spacing.
We should be monitoring the amplitude and the duration of the P wave. So I'll show you this in a second on a picture. We should also be monitoring the interval between the P and R wave.
So this is the time between those two sections of the complex. We should also be monitoring the QR QR S complex duration. So if we're seeing a full QR S complex, how long is it until the next one?
Is it sort of Oh, quite a long duration or are we seeing it straight away, and this will be able to determine whether we're Brady, Cardiff or tacky Cardiff as well. We should be monitoring the R wave amplitude and the QT segment. So we should be looking at the height of the R wave and then sort of the the segment between the Q and the T.
So RP wave basically, represents arterial and depolarization. So this is basically an essential step in the hearts conduction cycle. Then IP to Q waves show conduction across the A V node node.
So any abnormal abnormalities that you might see here could indicate conduction delays or blocks. So these, are the sort of places you would be noticing your A V blocks. Our Q wave shows the depolarization of the interventricular septum.
So this is usually a negative deflection after the P wave. And it shows, basically the the, ventricular septum depolarizing. So, sort of reducing the R wave shows a depolarization of the ventricles.
So this is the first positive deflection in the QR S complex. And this shows, the ventricles, again, sort of reducing. So rather than them working up to, sort of pump this shows where that the this shows the period of time where they're not contracting the S waves.
Show depolarization of the basal part of the ventricular walls. So it follows the R wave, and it's usually a downward deflection. And then the T wave shows repolarization even of the ventricles.
So this is where they are returning to the resting state. The QT waves show electrical systole. So this is basically, where the the time for the ventricles to depolarize and re polarise, which covers the whole of the electrical cysto there.
So our ECG and abnormals, so abnormals we will be seeing on our ECG would be bradycardia, which is obviously a slow heart rate. This could indicate excessive anaesthetic depth, hypothermia, vagal stimulation. And we need to be sort of intervening quite quickly with this, our tachycardia, which is obviously, an abnormally fast heart rate.
This could be showing inadequate anaesthesia depth. We could be this could be showing pain hypervolemia or hypercapnia. And when we're seeing tachycardia, we should again be, sort of intervening straight away, whether that's increasing anaesthetic depth or administering more pain relief.
Abnormals would be wide and bizarre. QR QR S complexes as well. So this can, sort of suggest ventricular premature ventricular contractions or ventricular tachycardia.
It can also suggest the electrolyte imbalances, or my myocardial hypoxia as well. We might also be seeing the absence of the P wave. This could be signs of, arterial fibrillation.
Hyperkalemia, and even, sort of like problems with, junctional rhythms as well. We may also be seeing extra P waves. So, this might indicate arterial flutter, tachycardia, or even an arterial premature complex as well.
So this basically suggests that there's some abnormality within a atrial, activity. We might also know loss of morphology and complexes. So this is basically the normal shape and structure of the P QR S complexes are not maintained.
So this can indicate, severe arrhythmias like ventricular fibrillation or severe electrical light electrolyte imbalances. And we need to be sort of intervening again with this straight away. So our normal Sinus rhythm, so our normal Sinus rhythm is a normal P QR S complex.
So on this picture, you should be seeing before the spike. So if we're looking at the first complex, you should be seeing a little, sort of upwards, sort of point, which is your P wave. Then you have a downwards point.
Which is your Q? The top spike is the R. Then back down to the S and then, the little sort of upward spike.
Slightly after your, R and S is your T. So we would be seeing normal shape and width of the QR S so we can see that, on this picture, the QR S is sort of not elongated. There's no delay.
We're seeing nice intervals in between, each complex as well. We're seeing a P wave for every QR S complex, and we're not seeing any arrhythmias present. And our heart rate should be normal as well.
So with our abnormal ecg S. So we're just gonna cover, a few of the more common ones and the anaesthetic. So first we've got ventricular premature complexes or VPC S.
So these are quite common with abdominal pain. Abdominal pressure. They can be seen sometimes during abdominal ultrasound just because we're putting a bit of pressure on the abdomen.
But they're quite commonly seen, in, like, abdominal surgeries such as your XL. Even sometimes in your bitch phase as well. If we've got quite a sort of deep, sort of, ovary or deep ligament that we need to break down.
So the photo on the right, where the arrow is pointing to, as we can see, there is wide complexes, and this sort of like premature beats that don't have any P waves. So if you look at this photo compared to the last one, you can see there's quite a sort of bizarre complex going on. So when we are, noticing this, we should be monitoring the heart rate.
We should also be, monitoring the complex progression. So if we're only seeing one or two, then I'd be quite happy to just monitor this, notify the vet and let them know. But if we are seeing sort of say, five or six in a row, then I'd be sort of wanting to intervene and come up with a plan of action.
If we're noticing this due to pain, then we need to be aiming to reduce pain by giving additional analgesia. And whenever we notice VPC S, we should be monitoring the blood pressure alongside the heart rate because we don't want the blood pressure to be becoming tachycardic. And we don't want our blood pressure to be drop.
Sorry, we don't want our heart rate to becoming tachycardic, and we don't want our blood pressure dropping either. So our ventricular tachycardia or V tac? This is usually a progression from the VPC.
So this is usually when, VA patient with VPC S becomes tachycardic. This then sort of develops into V tac. It can also be seen in our short patients as well.
So we will see tachycardia so usually heart rate of 200 plus and we'll see really wide, sort of bizarre P QR S complexes. So on the photo on the right, where the arrows are, your ECG will just be full of them. There will be no sort of normal complexes.
It'll just be a constant cycle. Of of, sort of spikes. So if we are noticing this we should be monitoring how long this is happening for, how fast the heart rate is.
We can also consider administering a lidocaine bolus as well. So I think this is usually at four megs per cig. And we have to do this quite slowly.
If we are not seeing any differences after boluses, then we can look to put them on AC R I but obviously, we should be consulting the vets before doing this. But basically, what we need to be doing is providing hemodynamic stability, and we need to decrease the heart rate as well. So moving on to our more Brady arrhythmias now.
So these are arrhythmias that you would see with our with bradycardia. So second degree, atrioventricular block or second degree? A V block.
So this is commonly seen with bradycardia and with use of alpha twos as well. Mhm. So as you can see on the right, we're seeing a navy block here where the red box is highlighting.
This is basically a P wave that is not associated with a QR S complex. So this is a P wave that is throwing on its own. If you look, but the two complexes in the middle of the photo, you're seeing a P QR S complex P QR S complex.
And then we're just seeing a random P wave for all night. So this is like I said, it's usually quite common with the use of alpha twos. And this is just because alpha twos can tend to make patients bradycardic.
So I normally would see this, in the initial phases, after, induction. And what we would normally see is bradycardia we'd see high, high blood pressure, then a drop in blood pressure and then sort of normal tensive. And usually after a couple of minutes or so once we've got the patient stable, usually an a V block resolves, if it's just due to the use of alpha twos, if it's a case of the heart rate is still dropping, blood pressure is not maintaining.
Very well. Then I would look to reverse the Alpha two. If that is not resolving anything, then I would be administering atropine to increase the heart rate again.
This is all in consult with the vet as well. So we wanna be making sure that we are monitoring how many complexes are seen. So like I said, if we're only seen in one or two, it's not a problem.
But if we're seeing multiple over sort of a two minute period, then we need to be sort of doing our interventions of reversing any cardiovascular depressant drugs. We need to be monitoring our heart rate in BP as well. So with our third degree a V blocks, these aren't as common.
But these are usually due to extreme bradycardia or severe stage heart disease. So there's no clear P QR S relationship, and the there is wide and bizarre QR S complexes as well. So in order to, sort of intervene with this, we need to be making sure as an absolute must we are reversing any cardiovascular depressant drugs.
So this is any of your alpha twos, even your opioids as well. And usually this results in surgical placement of pacemaker. And this is just because you, sort of, you your sort of, pacemaker is your S a node, which is where electrical activity of the heart is started from, and because this block is associated with a problem with the, sort of pacemaker of the heart, as you will.
Then essentially, we need to be replacing that with a mechanical version of it. So our capnograph so we're gonna be looking at the normals of crap. Grey.
So cartography is basically the monitoring of the concentration or partial pressure of carbon dioxide in every exhaled breath. It provides a continuous and noninvasive measurement of tidal Co two, which is the maximum concentration of CO two at the end of an exhaled breath. So it's very important because it helps to, reflect on ventilation status.
It helps us to look at respiratory function during anaesthesia. And it helps us to also identify that the anaesthetic machine is functioning correctly as well. So our normal ranges are between 35 and 45.
If we are using much higher analgesia or, sort of CRIS and things, then we can expect this to be around 50 which I'm happy with, as long as the other promises are fine with our inspired CO2. This should be below six, and we should be seeing like on the photo, a nice steady peak and trough, which should meet the baseline and not peak above the top line. So a normal trace is generated by the phase one baseline.
So this is the little line where zero is? Phase two is the expiratory uptake. So this is where your trough is climbing.
Phase three is the Alveola Plateau. So this is where it sort of straightens out at the top. And this is usually where ET CO2 is measured.
And then phase four is your inspiratory down stroke. So this is on the picture where we're falling back down again, and then this cycle should just happen over and over again. So with our cartography abnormals, so I'm just gonna run through the more common ones that we would see.
So first of all, we've got hyperventilation, so this is obviously reduced respiratory rate. This is usually due to the increased an anaesthetic depth or positioning. We would see a normal shape of the sort of capnogram, but we would see increasing in height.
And the ETCR two would be going above 50 or 60. And as this is happening, the respiratory rate will be decreasing as well. So if we are noticing this, we should be performing IP PV.
Whether this is manual or mechanical, we should be reducing our anaesthetic depth. We should even look to reposition our patient. Because, as I mentioned before, if we've got quite a large patient or, quite a, sort of elderly patient, then essentially, if they're on their back for quite a long time or on the side, then we're impacting the movement of the air ways and their lungs.
So I would always try and reposition. First of all, if none of your interventions are working, then we should be looking to then reverse any respiratory depressant drugs as well. So our hyperventilation.
So this is the second photo on the right, so this is usually, an increased respiratory rate. And this can be, sort of the capnogram. That you'll see can be from a number of things, such as a sampling of rumour over ventilation.
So if we're ventilating because they're hyperventilating, then if we ventilate too much, we can put them into hyperventilation. It can also be due to a light plane of anaesthesia pain hypoxemia or hypothermia with the Panin. So if we've got a patient with inadequate pain relief and then essentially they're going to be panting because they're painful, we're going to be seeing this on the CAPNOGRAM.
Normally, we will see an ET CO2 of below 35. It will be a normal shape, but as you can see on the photo, it's decreasing in size, so we're gonna be falling above the minimal baseline of 35. So if we are seeing this, we should be looking to maybe increase anaesthetic depth.
We should be looking to admin the pain relief, check our temperature to make sure they're not hypothermic. Check our circuits and ET tube. And we should also be reducing ventilation if we are assisting.
And we should also check SPO two for signs of hypoxemia as well. Because if we have got a low SPO two, then our patients are gonna be panting more. So we should be checking the SPO two as one of the first things we do with our reb breathing, which is the top photo on the right.
This is usually caused by inadequate fresh grass floor, exhausted soda, lime or a malfunctioning in spiritual valve. And it can also be due to a mucus plug in the ET tube as well. So we will see a abnormal shape that doesn't return to the baseline.
So as you can see, the shape is just sort of floating around in the middle, and we get in a normal shape to begin with. But then it starts to sort of round off. And the bottom baseline is not touching to zero.
So normally we would be seeing this in our non reb breathing circuits. So our tea pieces, you would see this quite often in sort of like your under 10 kg patients that are quite quite chubby. So if we are noticing this, we should be increasing our fresh gas flow to flush out the carbon dioxide.
We should be reducing dead space, changing soda line and replacing philtres on the respiratory valve as well. If they need replacing, then without expiratory resistance. So these, are normally, sort of like your shark fin appearance.
And it's usually caused by COPD obstructed ET tubes. The A PL valve is closed or a bronchial spasm, so it's to do with some sort of resistance within, either the patient's breathing, the circuit or the tube, so we should be checking the inflation of our bag. We should be checking to see the A PL valve is unlocked.
If we're checking this and there's no change, then we should be looking to replace the ET tube. If there is still no change, then we should be looking to administer a bronchodilator to just open up the airways with our inspiratory resistance. So this is basically the opposite way around to our expiratory resistance.
We'll more than likely be seeing a slant in and prolonged phase four, an abnormal phase three on the capnogram and an increased respiratory rate as well. This is usually because abdominal contents are pressing on the chest. It can be due to a diaphragmatic hernia, low fresh grass flow or any pressure on the chest.
So if you've got equipment on the chest, we could be seeing this due to the the the sort of compression it's causing. So if we are noticing this, we should be removing any pressure from the thorax. We should be increasing fresh fresh gas flow and We should even consider placing an NG tube to just remove any, sort of gas from the stomach, which could be causing pressure on the the, diaphragm or the thorax.
So at SPO two. So we're gonna be looking at what this is and what is normal. So our SPO two is measured noninvasively using a pulse oximeter.
This measures the percentage of oxygen within the blood. It detects hypoxia. We should be seeing normal ranges.
Between 96 and 100% we should be seeing a pulse complex for every QR S complex. That's where I was talking about the set up on your multi parameter. And we should be seeing a nice, steady and diro notch.
Sorry. Nice, steady and continuous. Diro notch.
We can measure this using different sort of ways. You, So this can be with the transmission probe on the lip, the ear, the testicles, the mammary gland or the pore. And then I'm gonna just put this video on and quickly show you what a normal SPO two should look like.
So, as you can see, our diacritic notch is sort of steady and continuous there's no real changes in it. Ranges at 99% which is absolutely fine. And, we're also if we had the ECG on I remember this video, we would be seeing a pulse for, every QR S complex as well.
So at SPO two abnormals, so these are readings below 96%. These are, traces that have a high diro notch, which is basically vaso constriction. A low diro notch, which is vasodilation a low inspired, CO2 pulses that don't sync with an EC with ECG complexes.
So pulse deficit and then SPO two, below 90% which would be resulting of hypoxemia. So if we are noticing any of these things, we should be looking to reposition our probe. So if we're on the tongue, then maybe look to reposition onto the lip, or re reposition to another area of the tongue, we might want to be wet in our tongue or wet in our probe.
We should really be using a swab for better contact in our smaller patients. Just because the weight of the probe can actually crush the vessel in our, much smaller and younger patients. So we're just gonna be getting an abnormal reading due to positioning.
We should be looking to increase our fresh gas flow rate so that we're pushing through as much oxygen as possible and removing the carbon dioxide. We should be checking our circuit to make sure there's no kinks in it. We should be checking our ET tube for the same reason.
And we should also be checking our soda line to make sure it's not exhausted. So our blood pressure So our blood pressure is important, for looking at cardiovascular health and we should be carrying this out for all patients under anaesthesia as well. So this usually tells us, about our perfusion, our anaesthetic depth and detecting complications as well.
So we can measure this, with two via two methods which are noninvasive and invasive. So our non invasive method is our Oslo Meric, which is usually what's used on the multi parameter. And then we can also do Doppler as well.
So our Doppler, is sort of much more, accurate in terms of systolic pressure. But it's also quite subjective, so I could listen to it, but someone else could, and they could get a different reading. Our invasive method is our direct arterial method, and this is usually where a probe is placed surgically and runs parallel, to, the arterial sort of wall.
So obviously comes to this is infection and then risks of, bleeding. But this is sort of like the most, sort of the most. What's the word?
It's the more, reliable of the two. The two methods. So our normal range is for our dogs.
Systolic pressure should be between 9140 whereas with cats, systolic pressure is 80 to 140. Our diastolic pressure in dogs is 50 to 90 whereas cats 55 to 75 and then our mean pressure in dogs is 60 to 100. And this is the same in cats as well.
So, normally, if I am seeing this, if I'm seeing the mean drop slightly, then I would monitor this. However, if the systolic is dropping at the same time, that's where I'd be, intervening. So that would be either, like a fluid bolus checking anaesthetic depth to make sure they're not too deep.
And then if we are still, not improving and we're falling further into, hypertension. Then I would look to discuss things like vasal presses with the vet as well. So our blood pressure abnormals.
So, hypertension, and hypertension. So hypertension is systolic blood pressure lower than 80 to 90 Or an, mean arterial pressure lower than 60. This can be due to increased anaesthetic depth, increased vasodilation, hypothermia, dehydration and certain drugs such as, Alpha two, and our opioids as well.
If we are noticing any hypertension, we should be regularly checking the depth of anaesthetic. We should be supporting hydration, and circulating volume with intravenous fluids or blood products. We should look to identify any bleeds as well.
And we should be administering IV meds very, very slowly. We should be reversing any cardio vs vascular depressant drugs. If, other interventions are not, causing an increase in blood pressure.
And we should be trying to maintain normal FIA as well. If we are doing all these in interventions and nothing is changing, that's when we should be considering our vasopressors, whereas our hypertension is systolic pressure higher than 160. Our mean, pressure is higher than 100 to 110.
Usually this is through stress and anxiety or aggression. It can be used because of certain drugs as well. So, like, our ketamine can cause this, and then initially metamed cause it as well.
It can also be due to a light plane of anaesthesia or pain. And it can also be because of medical causes such as renal disease, anaemia or hyperthyroidism. So we should be checking our anaesthetic depth.
We should administer analgesia as and when we need to. We should be stopping intravenous fluids in healthy patients just because this can actually dilute our sort of fluid volume. And we should be reducing environmental stress as well.
If we've done all this and there's no no change, then we should be considering beta blockers or calcium channel blockers as well. So recovering our patient. So, basically, the recovery period begins when the maintenance or inhaling gas is switched off and drugs are.
It's also when drugs are reversed and the patient begins to regain consciousness. So we should be monitoring this as closely as what we would do under anaesthesia. So we should be monitoring our heart rate, our respiratory rate, our temperature mucous, mene colour, C RT demeanour, recovery time pain, our eye position, and then our additional monitoring aids as well.
So there is studies to show how crucial the, recovery period is. So there was a study in 2008, which showed, that the recovery period is the highest risk period in anaesthesia. So 47% of dogs and 61% of cats and 64% of rabbit fatalities happened during the recovery phase.
And then in 2022 there was another study on around 100 and 60,000 dogs under anaesthetic in the UK. And the findings were around 1400 deaths within two weeks, and 43% of these occurred during the recovery period. So this is why we need to be, sort of monitoring these.
This this phase of the anaesthetic very, very carefully. So which patients are at risk during our recovery periods? So as we know, our geriatric patients are at risk, and this is just because they usually have reduced organ function and they can have some cardiovascular instability.
And they can also have reduced respiratory capacity as well with our paediatric patients, as I mentioned before, usually they have immature organ function. They have a higher metabolic rate, and they're more susceptible to hyperglycemia as well. With our sight hones, these are more sensitive to anaesthesia.
And anaesthetic agents, and they're also more susceptible to temperature changes so they can fall into hypothermia. Quite quickly, just because of the low body fat. And then when they are, sort of laid down in a position for a long time, they can have a problem with their muscles where when they try and stand, they just lose all coordinations.
So we need to be really careful with these patients for for that particular problem as well. So this is where we would support the positioning and analgesia as well with our brachycephalic breeds. Then, obviously, as we know, we've got, risk of regurgitation with respiratory compromise with very highly stressed breeds.
So we might look to put these breeds on, a sort of chilled CR I, just to help them relax in recovery. So this can sometimes be with metamed. And it just sort of helps to mildly sedate them so that they're not coming round and they're not going crazy.
This is more so for, recovering in Bowa because we don't really want them to be panting and crying and screaming because all this is gonna do is cause issues with the, sort of surgical sites that we've been working on inside the airways with our obese patients. We've also got the risk of complications, respiratory issues and cardiovascular stress, and then our pre-existing conditions. So we could have chronic illness like heart disease, diabetes or kidney failure.
And we could also have compromised body systems as well with our thoracic surgery, because we would have needed to have assisted with ventilation during the anaesthetic. We need to be making sure that these patients are ventilating on their own in recovery. So I wouldn't be leaving their side until I'm happy that they're awake and ventilating and moving around as well, so I wouldn't just wait until they've lifted the head.
I'd make sure that the ventilation is, working well when they start moving. Just because if they begin to pan, they can then fall back into respiratory distress with our spinal patients. Again, risk with this with this is, excessive movement can cause problems with the spinal cord.
We can also, sort of have issues with our urinary systems after spinal surgery. And because it is neurosurgery, we need to be very careful. Looking at our sort of, like neuro neurological checks or looking at our eyes, our sort of mobility and our reflexes as well.
With our ophthalmic surgery, we've also got the risk of, intracranial pressure. So we need to be monitoring our blood pressure very closely. We've got risks of, damaging the surgical site in recovery.
So again, these patients might be better with sort of a sedation CR I just in recovery to to sort of chill them out a little bit to prevent them from hurting themselves. I expected recovery complications. So as we know, hypothermia, hyperventilation, delayed recovery and nausea.
So our hypothermia is usually due to the anaesthetic affecting thermal regulation. Our hyperventilation is usually due to the anaesthetic drug effects. So we've had, like, respiratory depressant drugs.
Then we should be expecting a low. a low, respiration, a delayed recovery. So this can be expected in prolonged anaesthetics and then high analgesic use as well.
Just because of the effects of the drugs, It can just make the animals wake up a little bit slowly from the anaesthetic. And then our opioids can also cause nausea as well. So I would be monitoring for any, excessive salivation, any lip smacking.
And if I found this, then I'd just speak to the vet, and maybe we'd administer an antiemetic just to make him a little bit more comfortable. So our unexpected complications, so we've got cardiovascular instability. So this can be due to hypertension, arrhythmias or bradycardia.
And it can be because of the anaesthetic drugs, any blood loss in surgery, hypothermia, and then any pre-existing heart conditions as well. So we should be monitoring our heart rate and blood pressure and our mucus membrane colour. Throughout the recovery, we might also see dysphoria, which is basically a state of agitation or restlessness.
And it can be due to anaesthetic effects. Uncontrolled pain. And it can also be due to, side effects of drugs as well, such as ketamine.
Hypoxemia. This can occur if hyperventilation is left unresolved or if our airways are not managed correctly. So if we have got a patient that is as hyperventilated in anaesthesia, and then he is doing this in recovery, then essentially, if we're not picking this up with SPO two and providing oxygen, then we're gonna fall into hypoxemia quite quickly, which will then lead to some sort of cardiovascular instability as well.
Our aspiration. Pneumonia. More common in our obese breeds brachy palli and our G.
I compromised patients. This can be due to regurgitation, excessive movement, compression on the abdomen, and then also some drugs can can cause us to vomit and inhale it as well. And renal complications.
So this can be drug related factors If we've been using, NSAIDs without realising there's, a sort of chronic, or acute kidney injury somewhere. And it can also be because we're not monitoring blood pressure carefully as well. And we're not recognising hypertension or hypertension.
And sort of supplementing this, with either drugs or fluids. So in recovery, we should be using our surgical safety checklist. As I mentioned before, to look at a recovery plan to ensure the patient is safe alert, and we can alert any problems to our team and plan for interventions.
So we should be looking to discuss how well the anaesthetic went. So was it stable? Was there any events that we were a bit unhappy with?
So this can just be a tiny period of bradycardia. We need to be mentioning this. We need to be discussing the vital signs under anaesthetic.
So I usually just work out a bit of an average, and we need to be sort of discussing the vital signs when recovery began. So as soon as we turn off the gas, we should be doing, a hands on heart rate, respiratory rate and temperature. And then also her blood pressure as well.
We should discuss any medications administered. So our analgesia, any antibiotics, any antiemetics our premeds, what we were induced with and what we were maintained with, we should also discuss the procedure performed sometimes this is forgotten, and knowing what procedure has been performed helped us to one plan for any problems and if a problem did occur, it can help us understand why it happened as well. We should also note down any potential complications.
So with our brachy breeds potential compli complication is regurge or respiratory distress. We should also be noting down our nutrition and fluid plan. So sometimes in our abdominal surgeries, we don't want to be giving our, food in large amounts.
We might want to give really small amounts. Little and often, and sometimes we're on fluids. Do we want to keep them on on surgical rate, or do we wanna drop them down to maintenance?
When do we want to remove the fluids? And then, finally, we should be discussing our analgesic and antibiotic plan as well. So we should be running through what they've had in pre-med.
What? Sort of they've had it in drop. If they've had top ups, if they've had AC, R, I and when they're due next checks or next doses to be administered as well, and then we're just gonna quickly look at preparing for our emergency, so coding our patient.
So in order for us to prepare for emergencies, we should always code our code. All our surgical patients, we must ensure we fully understand the difference between these codes as well. So usually we have BLSALS and DNR.
So DNR is do not silt. So if this patient crashed, we wouldn't be, performing any compressions or ventilation. We will simply assist them with death and then pronounce them dead with our BLS, which is basic life support.
This is the backbone of CPR. This is what we should all be doing. If we don't have a code for the patient, we should be doing this until we've contacted the owner.
So we should be doing cycles of CPR, which last two minutes. We should be compressing and ventilating, to support the cardiovascular and respiratory system without any further monitoring aids. And this should be carried out, as I said in the initial crash period.
And then usually someone's on the phone to the owner explaining what's happened and asking, Do we want to continue? If so, do we want to continue with advanced life support? Or do we want to do another cycle and then sort of leave it as that.
We then have a LS, which is advanced life support. So this still involves cycles of BLS. But this is more intensive monitoring.
So this is where we'd be using our ECG and capnographer to give us feedback on our compressions, and ventilating. We would then be administering our reversals so we'd be reversing things like opioids and, benzodiazepines, any alpha twos as well. We'll be looking to obtain vascular access if we've not already got it.
We should do because we're under anaesthetic. So we should be making sure that that catheter is pain. And if we're unsure, place another one, place as many as we can get, Really?
And then we should also be offering so fluid support if it's required. So before we're moving into the recovery period with our anaesthetic patients, we should be making sure that all of these patients have a one of one or two of these codes so that if they did fall into any problems in recovery, as we know it's the most heightened area for complications, then we know we can begin either BLS or a LS or we can just not resuscitate at all because of the owner. Owner wishes.
So our take on points for today. We should now be able to devise a pre op pre op instructions for patients of a variety of species, life, stage and considerations. We should be able to plan for patients based on the life stages, conditions and procedures, specifically the fasting period.
We should also be able to maintain anaesthetic equipment properly, ensuring safety checks are carried out, and we should also be able to identify additional ways we can monitor anaesthesia. We should be able to identify abnormals and normals of our monitoring needs such as ECG, Capnographer, BP and SPO two. And we should be able to look to resolve these confidently as well.
And then we should be happy to plan for recovery and identify those patients who are at risk and what could happen to these patients and what we need to do if they did fall into an emergency. So that's everything from me today. So yeah, thank you.
