Good morning, my name is Josh Rayner, and I would like to introduce to you JHP Recruitment. JHP Recruitment are a specialist recruitment company working within the veterinary industry. We are able to supply both locum and permanent candidates of all levels.
Our team has many years' experience within the sector, and we pride ourselves on providing a professional and friendly service. If you are a veterinary surgeon, veterinary nurse, veterinary care assistant, practise manager, or receptionists seeking work in the veterinary industry, please feel free to contact us via email or telephone. I would like to welcome everyone currently logged in for this webinar, especially to all of those who have received complimentary tickets through JHP recruitment sponsorship.
Thank you all for your continued support, loyalty, and for all your hard work the agency. We hope you enjoy the virtual congress. For those of you who aren't aware, the JHP team is currently made up of 14 consultants, including 2 who worked within the veterinary industry in a nursing capacity for many years.
So we are well placed to assist you with any recruitment requirements. We have recently partnered with the webinar bets as we are keen to give something back to the fantastic candidates and locums to work who work with us. We feel they are the perfect company to assist us with this.
It would be great if you could visit our website after this webinar or ask our a friend that may be interested. We are also on social media, so please do follow us on LinkedIn, Twitter and Facebook to be the first to hear about our new vacancies that are available, as well as opportunities to gain top quality CPD through the webinar bet. We can help to supply staff, whether it be for one day to cover sickness or annual leave to ongoing full-time locum and permanent roles on a part-time or full-time basis.
Our consultants will listen to your needs and we'll do our very best to find the perfect role for you or the perfect team member for your clinic. As well as dealing with thousands of first opinion clinics, we also deal with them in referral centres, hospitals. And hospitals all across the UK as well as having clients in Europe, Australia, India and the Middle East.
If your current clinic is seeking staff or you're seeking your next role, please feel free to contact us via email or telephone. We also offer a referral fee, so if you have a friend seeking work and you pass us their details, once we have placed them in a locum or permanent role, you will be sent back just to say thank you. If you're seeking work in the UK or abroad, we are confident we can help find you your dream role.
I hope that you enjoy the webinar and feel free to browse our website to see if you like the sound of any of the vacancies on offer, including a head nurse role in Dubai. Thank you. Thank you very much for that, Josh, and Catherine has put the link to your website in the chat box for all attendees, so you can use that link to browse the website as Josh mentioned.
So, it's my pleasure to introduce Louise O'Dwyer, who gained her diploma in advanced veterinary nursing in surgery in 2004, followed by her diploma in advanced veterinary nursing in medicine in 2007. In addition, Louise is a veterinary technician specialist in emergency and critical care and also anaesthesia. Louise has contributed to over 35 books, journal articles and book chapters, and lectures worldwide on aspects of anaesthesia, emergency and critical care, surgery and infection control within Europe, Australia and the USA.
Louise spent 15 years working in at Pet Medics in Manchester, firstly as head nurse and then clinical director. And then in October 2015, Louise moved to vets now to take up the position of clinical support manager. Louise's interests include all aspects of emergency care, but in particular trauma patients, as well as anaesthesia, surgical nursing, infection control and wound management.
So I'll now hand over to Louise so she can begin her first presentation. Thank you very much. And again, we, we want to thank, JHP recruitment as well for sponsoring these webinars.
So, it's pretty early in the morning. It's pretty early for me. It's not the earliest that I've done this.
I think 2 a.m. Is the earliest I've ever done a webinar, but hopefully, everyone is awake and listening, and it's full of caffeine, cause that's what I did in the 30 minutes before we started.
So, first of all, I'm gonna do, a session on, anaesthesia for geriatrics, and then the second session's gonna be on nursing recumbent patients. And I have to confess, I do have a real soft spot for geriatrics. I think they often get really quite a pretty rough deal when it comes to anaesthesia.
And often, we really don't consider that these patients as being, you know, very different to the rest of the animals that we're dealing with, but they really do. Have very, very different considerations. We really should be looking to how we can tailor things to make things better for these patients.
So, what is a geriatric patient? Well, you know, cats, we know will generally live up to about 15 years. Some can go on much, much longer as dogs, really quite a big variation in their lifespan, but often, you know, well into their teens, hopefully.
And we generally consider animals to be geriatrics. Kind of once they've achieved a certain percentage of their life. But for me, certainly any any animals that get over 6 or 7 or 8, I will start thinking what I want to do differently with those patients.
And we are seeing more geriatric animals in our clinics, you know, over the past 10 years, more now, Things have advanced. We've improved nutrition, we've improved preventative health care for these patients, and it does mean, ultimately, they are living much, much longer lives, and we're seeing more of them within our clinics. And when I talk to nurses about anaesthesia, and I talk about it in general, you know, often what they will say to me is they tend to consider the procedure rather than patients, when I, I will talk to nurses and then they will maybe have one blood pressure monitor and I talk about which patient's gonna get that blood pressure monitor if they've got two different animals in the theatre.
And they will confess that it's often the procedure that they think about. They'll think about that monitor being used on a patient that's having a cruise ship repair, rather than using it on the geriatric cat. That's in for a dental, because it's just having a dental.
So, hopefully, you know, this will change, you know, when we talk about what's happening with these patients, it'll change the way we think about them. And we think about approaching anaesthesia and monitoring these patients and all those different factors. So, as you said, really things have begun to change.
So society has really begun to change. You know, if you talk to your grandparents or your parents about what you're doing with your animals, you know, what procedures they're having done, if you talk about what we're doing within our clinics, you know, they're often they're quite surprised at how far we will go now in terms of what we will do for our geriatric patients. So there really are big changes, you know, in terms of client expectation as well.
And as we said, it means that a larger proportion of our patients are sticking around longer, which for me is good. Also, there is very little correlation between physiologic and chronological change. You know, often, you know, we don't necessarily think about what's going on in terms of organ impairment, but we do, in these patients, get development of age-related disease processes.
So we start to see, and we'll talk about this in a second, we start to see changes in things like the cardiovascular system and the respiratory system that we often don't really think about happening until we stop and think about it. There is, of course, gonna be a big variation between species and breed and individual. You know, you're always gonna get those really, really old animals that, you know, we get the blood work back and they've got literally no changes on there whatsoever, but that doesn't mean that we shouldn't do something differently for that patient, because they're going to have some underlying changes, which we can't necessarily see on that blood work.
So what I would say is we want to really consider each of these animals individually. As I said, we start to get these organ changes. They're all individual and that maturity in terms of organs depends on species and it depends on breed.
Organ maturity will happen, you know, from these patients being born, and, you know, we get some big changes happen as they are neonates, as they become paid paediatric patients, as they go on to become adults. And again, the same things will happen in our geriatrics. So we really want to think about those organ changes that tend to happen.
As patients get older and as I said, generally animals over 6, maybe a little bit different for smaller kind of breed dogs, but certainly anything over 6, I'll start thinking about what could be happening and use that age really as a guideline as to what's going on in these patients. As we said, different organ systems change. We get changes in the cardiovascular system, and, you know, these account for many of those alterations because of those age-related changes in disease processes.
What will happen in that cardiovascular system is we get a loss of elasticity. We start to get collagen being laid down, and that collagen being laid down means we've got decreased vascular capacity. So we can't, we don't get as much stretch.
In our cardiovascular system. Also, we get increased peripheral resistance to cardiac output, because we've not got as much stretch. If the heart has more difficulty pumping that blood out with each heartbeat.
So again, that's something we want to think about. Some of our drugs can cause vasodilation, some of our drugs can cause vasoconstriction. And if we vasoconstrict these patients more, that's gonna increase that peripheral resistance.
So maybe those aren't the drugs that we want to use. What this all means, as we said, is it's increasing work for the heart. These patients are trying to maintain that cardiac output.
They're trying to maintain that volume of blood, ejecting from that heart with each heartbeat, despite these patients, the vascular systems not being able to stretch, not being able to vasodilate as much. What will happen over time, if you think about that heart, having to work harder, having to work harder, having to work harder, will get hypertrophy of the ventricle. That ventricle will become enlarged, yeah?
And that can start to Again, give us further problems. Ultimately, this, what will happen is it will increase the oxygen demand because of those changes in the myocardium. And what we will see is you can often see increased blood pressure because of that vascular resistance, because the, there's not that much stretch there, there's not that vasodilation there.
And again, because of that hypertrophy that's happening with those, those ventricles. Additional things that can happen, we can start to get endocardium fibrosis. So again, this will decrease compliance.
This will decrease kind of stretch within the heart. We can get val valvular disease. We know, you know, cavaliers, we know, we, we, we will see a mitral valve disease in those patients very, very commonly.
And what will happen in valvular disease is those valves aren't snapping shut as they should do normally. So, Blood is able to kind of regurgitate back into the atria, and that will decrease stroke volume. That means there's not as much blood in those ventricles to be pumped out with each heartbeat.
Other things that can happen, we can start to get calcification within the heart. We can start to get myocardial fibre atropy, again, as those fibres to begin to begin to kind of, as they start to atrophy, as they start to reduce, in effect, that's gonna drop contractility and that in turn is gonna drop cardiac output. We get changes in heart rate and heart rhythm.
We can get patients that develop arrhythmias, we can see pacemaker cell atrophy. So again, We're not going to have normal conduction in the heart because of that. We also can see decreased barrow receptor activity.
So when patients do become hypertensive, and we know hypertension is really, really common under anaesthesia, the body and the vascular system is not recognising that as effectively, and so that it's gonna respond much more slowly or may not respond in a normal fashion at all. We also get changes in our respiratory system as well. So we get upper and lower airway changes.
In the upper airway, we get decreased protective airway mechanisms. So, we are going to have, reduced laryngeal function. We get reduced pharyngeal protective reflexes.
You know, these patients often will get, you know, animals can often have a little bit of laryngeal paralysis. I had, a collie that I lost, a year ago now, and I, I'm pretty sure that he had a degree of laryngeal paralysis, because I could hear it in his bark, his, his voice changed. He would also kind of cough up food occasionally.
It wasn't at a point where it was a major issue, but I think often people are not aware that these things happen and, you know, those reflexes there for, they serve a very important purpose. Also we get increased pulmonary secretions, viscosity. So again, these patients have more difficult if they do have lots of mucus and things like that, coughing it out, you know, that coughing happens for a reason.
We've got an increased risk of aspiration as well overall because of these factors. In the lower area, we also get changes. We get a decreased efficiency of gas exchange, and that happens because you start to get things like wasted at the diaphragm, that is that it's in effect muscular.
And again, that's gonna mean that these patients have reduced tidal volume. We get wasting of those intercostal muscles. So ultimately, we get a decreased total lung expansion.
They have less alveoli within the lungs, and they also have decreased alveoli elasticity as well. And what we can start to see, and we'll talk about a ectois more when we talk about recumbent patients, but we can start to see a electticis, we can get these collapsed areas of lung, and ultimately, we can start to happen is we can get a ventilation perfusion mismatch. What that means is we've got bits of lung that are getting blood to them, but no oxygen supply and vice versa as well.
We have an increased closing volume, we have a lowered functional residual capacity, a functional residual capacity is a little bit of air that is left in your lungs at the end of expiration. If you breathe out, you can all breathe out a little bit more after that. And that functional residual capacity is really, really important when we think about anaesthesia because it maintains oxygenation when patients are apneic.
And patients become apneic when we anaesthetize them. When we induce anaesthesia, when we sedate them, we're gonna have a, we're gonna have reduced respiratory functions, often up to about 30, about 30%. So ultimately, what that means is they have a decreased PAO2.
PO2 is the partial pressure of oxygen, so a decreased amount of oxygen levels within their blood. We get profound muscle relaxation. They have little active chest excursions.
So again, they're not breathing normally, all of this can decrease tidal volume and result in hypoxemia. So again, we'll talk about this later on, but this means, what's so important to think about pre-oxygenation of these patients, if they are just under sedation to make sure we're supplying oxygen in some sort of way. And in these patients, I will consider, you know, is it worth us thinking about ventilating these patients throughout that procedure because of all these factors?
And we can also look at things like positive positive end expiratory pressure, which means we don't allow those lungs to completely exhale. We're always maintaining some pressure in that patient's in in in that patient's lungs. So when we're looking at these patients, and again, for me, it's really important that nurses are involved all the way through the, an anaesthesia process.
I wanna check these patients prior to anaesthesia so I know what normal is. So, I'm regularly gonna be, assessing respiratory rates and depth and pattern and lung sounds in these patients. If I do have issues, I want to think about why those could be going wrong.
We'll talk about this later on, but I'm a big fan of using pulse oximetry, Particularly in patients that during recovery, because that can, again, tell us if that patient is able to maintain their oxygen saturation when we take them off some oxygen. We could potentially do in a look at doing blood gas analysis, but I think realistically, for most of us, and that's not gonna be a possibility. And for all those of us that have that capability, we're still not gonna do it that often, realistically, in our geriatric patients.
So I think pulse, pulse oximetry in those patients recovering is really, really useful. The central nervous system changes. We get increased incidences of what we call central ischemic episodes.
So, kind of stroke-like episodes. And that's because we start to get cell death and dysfunction in our central nervous system, particularly in the brain. And this is often the mechanism behind, behind post anaesthetic cognitive dysfunction.
So this is when we see anesthetic-related brain changes in patients. Now, we don't recognise it as much in, in veterinary patients as they do in human patients, but in humans, it's well recognised. And I think we probably, if we looked at it, see it quite a lot in our veterinary patients as well.
So this is animals that aren't just quite normal once they've had the anaesthetic, and old will often, you know, just put it down to them getting older. We don't necessarily relate it to that, that procedure that that patients had done, but we are beginning to realise that it does happen. And this happens because when you're younger, you have what we call a plasticity to the central nervous system.
It can adapt. And older patients don't have that natural reserve. They don't have that plasticity.
So what we see often. These post-anesthetic syndromes, so things like blindness and deafness, and behavioural changes. So animals, not toileting as they would do normally, things like that.
So, again, I would never want to think that I've done an anaesthetic on a patient, and that is an issue. You know, I want that animal to go home better than it did when it presented in the clinic for whatever procedure it had to have done because we fixed whatever needed fixing. We get hepatic system changes, very important when we think about anaesthesia because all of our drugs are gonna be cleared, or the vast majority of our drugs are gonna be cleared via the liver.
The liver is amazing, it's got massive regenerative capacity, but that's not gonna be quite there as much in our older patients. And our older patients, They're prone to hepatopathy. They have reduced immune function.
So again, the risk of things like bacteremias. They get reduced synthesis of albumin. So albumin is really important in these patients because most of our anaesthetic drugs are going to bind to albumin.
So if you've got reduced albumin levels, those drugs are gonna exert a, a greater effect. They also have reduced glucomiogenesis, so again, we can start to see hypoglycemia in those geriatric patients as well. So ultimately what we get is reduced drug clearance, we get reduced protein binding, so those drugs have got increased effective concentrations, they've got a greater effect.
We can also decrease the decrease production of clotting factors as well in these patients. So in those ones where they're having a big procedure, doing things like bule mucosal bleeding times is a very simple thing to do is really worth considering, particularly when we're concerned that major blood loss could be an issue for that patient. Renal system, we start to get changes as well, so we can see things like hypertension.
We can see that secondary to renal disease. We can see it associated, with hyperadrenal corticism as well. Cats, they're the most common ones that we're likely to see an increase in blood pressure with age, and again, that's often related to chronic kidney disease in cats.
These patients are gonna have reduced renal reserves, and as we know, our kidneys don't have any regenerative capacity. So, again, it's really important that we know what's going on with these patients' kidneys beforehand. Some of these, changes can be down to cardiovascular changes, so we're not getting normal blood flow to the kidneys.
This is again, why monitoring blood pressure is so important in these patients to make sure we are getting blood flow to those kidneys. They also have reduced number of glomerulline nephrons and they have a decreased glomerul filtration rate. So overall, those kidneys are not likely to be functioning as they were when these were, were, were younger patients.
They get tubular changes, so they have a decreased ability to concentrate urine. They have a decreased ability to to excrete hydrogen, so we can start to see, alterations in acid-based balance. These patients often can have a, a, a metabolic acidosis.
And with our blood pH is not working within the normal range, we can start to see, we will see changes in drug sensitivity. All the drugs that we use in patients are designed to work at a normal blood pH and if that's not normal, we can see alterations with that. These patients can often be anaemic, we can see decreased production of erythropoietin.
We can also see decreased intestinal iron and vitamin B12 absorption. So we can see, you said, anaemia in these, in these geriatric patients as well. GI system, we've got a higher incidence of chronic intestinal problems.
They have reduced lower esophageal sphincter tone. So again, they're likely to regurgitate more under anaesthesia. They tend to have a lower gastric pH, so it's more acidic.
So if they have reflux, if they regurgitate under anaesthesia, we can see a really major esophagitis. So again, we could start thinking about giving things like, proton pump inhibitors, like things like omeprazole in these patients for a period of time prior to the anaesthetic just to increase that gastric pain to. Make sure if they do regurgitate that it causes less issues.
These patients may well also have malabsorption. As we said, we can see anaemia. So if they're not absorbed in things like iron properly, that can be related to an anaemia.
Musculoskeletal changes, so we get alterations in elasticity, blood flow, they have less muscle mass. They're less flexible in terms of the joints. They often have arthritis.
So I think it's really important in these patients. Particularly that we think about positioning, we think about padding, we think about all of those things. These patients, you know, we force them into positions when we're doing surgery, you know, these patients often come in for exploratory surgery, you know, going into their abdomens.
They're on the back for a long period of time. They've got respiratory changes, so that can give them problems. We're tying their legs out into abnormal positions.
And these patients could be really, really uncomfortable. Post-operative live because of that. So I'm really careful when I think about positioning these patients.
I will be really gentle in terms of restraints. I really pad them well as well. Yes, because we're concerned about things like decupi ulcers, but just to make sure they're comfortable.
And the same applies during that recovery period as well. I think it's very easy to have these animals in oppositions and forget that we're doing that. So, you know, really consider all these factors in them.
In terms of temperature, they have improved temperature regulation. They've got a decreased metabolic rates. As we said, they tend to have less fat, they tend to have less muscle.
So we get changes in body composition. So they can better get colder much more quickly. Again, our paediatric patients do, but geriatrics, it applies to as well.
So what we can see is a slow recovery from anaesthesia. We could see a post-anesthesia hypoxemia as well if they're shivering. If you shiver, you massively increase oxygen consumption.
So again, if that's a factor, think about supplementing oxygen oxygen in these patients. So in terms of anaesthesia, I really want to think about putting together a plan, thinking about that individual patients, thinking about the underlying diseases, what they've got and how that can impact, what problems we're likely to have related to the anaesthetic, what problem that patients have got. Think about pain management.
These patients can be more painful. But a, a normal age, than an adult or a younger patient. So, these are all things that I consider when I'm looking at pre-meds, I think about drug, induction agents that I'm gonna use and for pre-meds and drug, induction agents, I really think about dosages.
As we said, if these patients are hyper-albumic, we maybe need to drop those dosages down. Think about a maintenance, think about recovery. Think about problems that we're likely to see in recovery.
Think about monitoring these patients, what we're going to do if things go wrong. So just planning it all really for those individual, patients. We'll start off by talking about the plan.
So, as I've probably said this in other lectures, I will think about the health status of that patient, that complaint that they're presenting with, what, what's wrong with them, how long it's been going on for, how's is any associated symptoms? Are they vomiting? You know, do we know they've got a stomach full of fluid?
Do we want to empty that out prior to anaesthesia or immediately after induction? What drugs are they on? When I talk about exposure to drugs, I'm talking about what medications are these patients on?
Do we want to continue with those medications? Do you want to stop some of them for a period of time preoperatively? And again, that's a discussion that we need to have with our vets.
I will try and get an anaesthetic history as well for that patient to see what they were sedated with last, how they, any problems that they had under anaesthesia. And I also want to know when they were fed last. So, we generally fast our patients for about 6 to 8 hours, and for me, that's really important in geriatrics, as we said, they could become hypoglycemic.
So I really want to factor that in. And I'll try and get those geriatric patients high up on the ops list. So I try to get them anaesthetized first so I can Get them recovered and get them up, get them moving around and get them eating as well.
So when we admit these patients, we want to get a really, really good comprehensive history. I want to talk about food consumption. Are they eating normally?
Have owners noticed any changes? Have they started to lose weight? What's their activity level like?
What are these animals used to doing normally? Has the owner noticed any behavioural changes? And again, as I said, talk about concurrent disease process and think about how that can impact on that patient's anaesthetic.
Particularly, I want to talk about sensory impairments. We forget that these patients are often deaf, they often can't see properly. I would say, you know, probably 80% of all our geriatric patients can't see normally.
If you think about geriatric humans, most of us, I'm gonna say I'm geriatric. I'm not, I'm getting there. Most of us wear glasses, yeah.
And our animals are exactly the same. My old cat. I'm pretty sure that he's deaf.
Yeah, I, I have to, you know, really get his attention. He, he no longer comes home if I shout him. He goes for a little potter in the garden, but doesn't go out very much.
He likes going to the next door, but one neighbor's house, so I have to go round and pick him up from there because he can't hear, and that's a big factor for our patients in our clinic. We put them in this new environment, these unfamiliar surroundings, and it's very stressful for them. And often they become aggressive and we put that down to being old and grumpy, which some of us are.
But again, sometimes it's just because they're really, really frightened and they're in this new environment, and we do pretty awful things to them, you know, we inject them, we do all sorts of other things. So just really, really consider that. As I said, we want to do that clinical examination of that patient.
I want to assess that patient's major organ systems. I want to know what their heart rate is. I want to listen to their lungs, all those factors before we anaesthetize them.
Look at relevant drug lab testing that we're going to do. Think about how we're going to do radiographs. For some of these patients, I wanna, you know, I would recommend getting an ECG on them so that if they have got things like arrhythmias, we know about it before we get these patients any drugs.
And we're also gonna ASA score them. So ASA is the American Society of Anesthesiology. So this classifies patients as kind of their risk status from 1 to 5, or category 1 patient, normal, healthy, no issues whatsoever.
A, a category 4 patient has got systemic disease that's a constant threat to life. So this will be patients that have things like heart failure that is decompensated. They're on medication, but things aren't working particularly well.
So I would say probably a lot of our, most, all our geriatric patients are probably going to present as an ASA 2 or 3. Depending on what disease process they've got going on. And an ASA patient of 2 or 3, maybe is, you know, a 2, maybe it isn't on that medication.
They've got some heart disease, what have you, but they're doing all right. A 3 is a patient that's probably already on some medication, but they're coping OK at that point in time. So it really makes me stop and think about, does this patient need something else doing?
When I'm putting together that plan, I think about the procedure, as you said, the duration, the type of procedure that that patient's undergoing, anticipated postoperative pain. As I said, I will consider these patients to be more painful than adults and younger patients, even when they're having minor procedures done because they're, they've lost that, that, you know, they have reduced mobility, they have osteoarthritis, all those things that, that can make them more painful. So I really factor that in.
So I think about the degree of haemorrhage, particularly considering these patients may not have normal clotting factors, they can have anaemia. So again, it's not a concern. These patients for me are always going to be on fluids.
I will generally run my fluids at . Kind of 3 mL per kilo per hour for cats, 5 mL per kg per hour for dogs, but I may well go a little bit higher if needed in these geriatric patients. And also considering antibiotics.
Again, that's going to be ultimately down to the vet, but we are moving away from giving everything prophylactic antibiotics, even for some orthopaedic procedures. I want to match that patient's anaesthetic drugs, so particularly things like pre-med to the temperament temperament of that patient and for these geriatrics, often we will just go with an opioid. We may not necessarily use things like Aceromazine if they don't require it.
So again, looking at that individual patient, thinking about what's relevant. Making sure we've got everything set up and checked. This goes for any patients, but making sure we've checked our anaesthetic machine, we've checked our anaesthetic circuits, everyone's happy with what they're doing with the procedure, considering restraint and position, as I said, particularly knowing those geriatrics are old and creaky and thinking if we do want to ventilate them, how we're going to do that?
Is everything set up, ready to go, people happy to do that. For the breeds, I will also consider things. So, particularly, you know, we'll talk more about giant breeds.
So, Dobermans, we know, can have voriebrand's disease. They'll often have cardiac disease. The same applies to boxers.
Snouters get something called, sick sinus syndrome, so they can have arrhythmias. And our giant breeds, we know, also commonly have cardiac disease. So thinking about, you know, common things are common.
So again, making sure that we know where we are in terms of those cardiovascular changes, those respiratory changes that we see in those patients and thinking about do we need to do something differently if that's an issue. And then as we said, we will ASA score them. In terms of preoperatively, I, as we said, we will fast these patients for 6 to 8 hours, but they stay on water.
I tried to get these geriatric patients to be the first procedure of the day so I could get them up, get them moving around, get them back to normal as quickly as possible, and get food into them. Put that individual anaesthetic plan together for that patient. As I said, we'll have them on IV fluids, but we don't want a fluid overload them because that can give them problems.
Thinking about some preemptive pain relief. Most of my patients are going to have an opioids, probably commonly low dose methadone. We can start low dose depending on the procedure, and we can always give them more.
That's the beauty of our things like our pure opioids like methadone, because if they need it, we can give them more. It's so titratable. I will keep them warm, so I will try and, and, and, and maintain normal temperature.
I don't want them to get too hot before they go into a theatre. But as we said, we know these patients are going to get cold. So we will put things like little jumpers on them.
We will make sure they've got a well padded, kennel where we can put some heating in there if we want to. And, as I said, pre-oxygenating these patients is really, really important. You know, 3 to 5 minutes prior to induction is so important to these patients because they have got those respiratory system changes.
We're gonna pre-med these patients commonly, but as I said, I'm not going to necessarily do what I would normally do in an adult patient. We pre-med them because it will reduce the amount of induction agent that we're gonna use. It's going to decrease the need for anaesthetic drugs for maintenance.
But again, I will look at that individual patient, look at their temperaments, think about the procedure, think about the underlying disease process, and we'll select agents accordingly. I'm always gonna have some sort of analgesia in there. So again, as I said, I'll normally use an opioid.
We consider non-steroidals carefully in these patients, and hopefully what we get if we get a good pre-med is we get a really nice recovery for these patients as well. In terms of pharmacology, as I mentioned already, these patients are very different in terms of their drug absorption, their metabolism and their elimination. So, really think about what we're doing in that individual patients.
As I said, they often will have lower amounts of total protein and albumin. So those drugs, if we're, if that's the situation that we use, normally bind to albumin, that's the way they carried around the body, are gonna have increased bioavailability. They're gonna exert a greater effect.
And on top of that, if their kidneys and their liver aren't functioning properly, we can get reduced clearance of these drugs. Also, Then we can get a variable response to cardiovascular medications as well. So again, some of our cardiac medications, we may actually withhold prior to anaesthetics.
It very much depends down to an individual vet. And also, as you said, we can see GIA changes as well in these patients. So we may want to look at adding things in like proton pump inhibitors just to increase that gastric pH just to, if that patient does regurgitate or join an aesthesia, hopefully we can cause less of a problem.
So as I said, careful about fasting times, I will generally starve them for no more than 6 hours and they only have water taken away once they're pre-medded. They're all gonna have fluids, we want to have interrupt fluids to replace those insensible losses. So again, you administering fluids carefully, so ideally using things like fluid pumps to make sure we are.
Not overdoing it with fluids, but equally to make sure they're getting what we think they need. Really consider haemorrhage. So, as I said, if it's a, an issue for these patients, I want to know what we're going to do if they do have blood loss.
And I will calculate that blood loss during that procedure. So, for me, as a ballpark, Joe, most, most patients have a blood volume in cats of about 60 to 70 mL per kilo. Dogs about 90.
I always remember 66 in cats, 88 in dogs. So I'll calculate that patient's blood volume preoperatively that I can keep an eye on how much blood they've lost during that procedure. And also thinking about how we're going to get fluids in.
Ideally, we want to get these fluids, these fluids need to go intravenously. There's no point giving subcutaneous fluids, but if these patients are having major procedures, think about putting things like central lines into them as well, if we know that they're going to be in for several days and on fluids for several days as well. Drug choices, we wanna again consider individual drugs for these patients, opioids, very safe for geriatrics, but just consider the effects that they could have.
They often will cause a decrease in heart rates. Normally it's not much of an issue. And you can get some respiratory depression.
Normally it's an issue if we give these drugs under anaesthesia and fairly high doses. We use lots of fentanyl, and we can see these, you know, we often do see, heart rate changes. We know if we give a bolus of things like methadone under anaesthesia, we will cause respiratory depression.
As long as we know what's likely to happen, we can keep an eye out for it. And then know what we're going to do if that becomes an issue. Benzodiazepines we will commonly use, they cause good sedation when used with opioids, if we've got fairly old patients or we've got fairly sick patients.
We can use aromazine in geriatrics, it does cause some vasodilation. It can cause some hypotension. So we'll use it at a very, very low dose.
And alpha 2 agonist, we generally avoid in our geriatric patients. For me in our hospital, we do, just because it has such great effects on that cardiovascular system, it really, you know, How we really, you know, reduce, cardiac output and all those things. Normal healthy patients could cope with that.
That's fine. It's a great drug. But in geriatric patients, we can start to see further problems.
Just a little slide on anticholinergics. So things like atropine, we used to use as part of our pre-med when I first became a nurse. We don't do that anymore.
There's no need to do. You know, we used to give it for reasons in that. A lot of the drugs that we used to use 20 years ago would cause a bradycardia or 30 years ago.
So we gave it for that reason. We also used to say we would give it to dry up, saliva secretions. We know it just makes them thicker.
And so they're more likely to include things like ET tubes. That was because we used to use drugs that were really irritant to the respiratory system, to the airways and would make these patients hyper salivate. That's not the case anymore.
We calculate these drugs if these patients need them, if they have issues under anaesthesia, but we don't give them routinely. And if we can get hold of it, we would generally use the glycopyrelate if this patient had an emergency. If they do become bradycardic during that procedure, but I realised getting hold of lycopyrolate these days is not always that easy.
So for induction, as I said, peroxidate these patients for 3 to 5 minutes. I consider the use of co-induction agents, so we will often use things like benzodiazepines and fentanyl alongside or just before that induction agent because it will really reduce the volume that we needed to give. So we use lots of things like midazolam.
And these drugs are useful because they've got minimal cardiovascular effects, and we're dropping the amount of induction agent that we're using, which will have more of an effect on the cardiovascular system. The one thing we never ever do is mass inductions. These have resulted in a 6 times increase in anaesthetic related death and hopefully no one is doing this anymore.
So as I said, lots of choices available in terms of induction agents. As I said, we want to pre-oxygenate and propofol, still a good choice, short duration of action. If we use a single dose, it's metabolised very, very quickly.
Alfaxolone, I think it's becoming increasingly commonly used again, good choice. To those geriatric patients, short duration of action, rapidly metabolised. If I'm honest, I'm probably likely to go with faxolone for those geriatrics because we get a little bit, a little bit of an increase in cardiac output and in heart rate of these patients, which can help to maintain blood pressure if we are concerned.
And we can use both of those with, as we said, things like midazolam or benzodiazepine is a co-induction agent, which will really reduce the dose that we need to give to our patients. Other things that we can use are things like ketamine and benzodiazepines. We generally would avoid this in these patients because ketamine is a sympthomimetic, so we will get a little bit of an, we get an increase in heart rate in these geriatric patients.
So, if we're concerned at all about them having any degree of heart disease, we'd probably avoid ketamine in those patients. Fentanyl, benzodiazepines, great combination of the very, very sick patients because it has really minimum cardiovascular effects. As I said, inhalation agents, that's an induction agent, no stressful for our patients, stressful for us.
Hopefully no one does this anymore. In terms of inhalation agents, we, yeah, whether we use, you know, isofluoride or sevoflura, I am not particularly worried. I generally use sevoflurane for, patients where I'm concerned about, intracranial pathology.
So patients where I'm concerned about brain tumours, patients with head trauma, those are the, so neuro patients, the ones where I would use, sevoflurane. But both of them titratable. We want to use as little as we possibly can do.
And for those agents, recovery is really dependent on respiration rather than metabolism. Again, what I would say is try to, you know, we want to have good pain plans in place for these patients, so we don't have to use inhalation agents to keep our patients, you know, we're just using them to keep them asleep on the table, not to control the pain. Because, you know, inhalation agents are the biggie in terms of causing hypertension.
They cause a dose dependent vasodilation. And that causes that hypertension. We could consider things like intravenous agents, they can be titrated, but again, they need to be metabolised by the liver.
So for most patients, it's not really going to be something that we're gonna do. We're likely to have an increased recovery time because these patients have got slow metabolisms, as well. So not normally something we would go for.
Intraoperatively, I've said this already. Remember patient comfort during post-surgery. Really think about carefully positioning these patients where we either know they've got osteoarthritis or if they're old, they're likely to have a degree of it.
You know, I only need to sit awkwardly for a, a length of time. And I know about it the next day. I know about it that night because I can feel it in my back.
These patients, and that's probably from being an old nurse as well, which is not gonna help. These patients have got reduced muscle wastage, they have to have arthritis. So again, the, you know.
We think about padding them and all those different things, because if we don't do that, they're going to be so uncomfortable postoperatively. They also have reduced flexibility. We've all probably been there when we're trying to take some X-rays on a geriatric patient or something like that, and we're like, oh, these limbs really won't go into the position that I want, we want them to do because they don't have that flexibility available.
And aesthetic circuits, I'm not really going to talk about. We're gonna use what we need to use for that patient. So whether we use a non rebreathing system or a rebreathing system like our circle circuits, non rebreathing non rebreathing systems have got reduced resistance in the circuit, which is why we select them for smaller patients, but We've got those high fresh gas flow rates, with the breathing in cold, dry gases that can contribute to the hypo hypothermia, but as we said, things like our circle systems, they've got all those valves in for reasons, but that will increase resistance within that whole circuit.
But we pick them for the size of the patient. In terms of monitoring, we want to monitor these patients carefully and we want to intervene really early as well. I will start intervening probably, you know, when things start to trend downwards in my patients.
Using things like oops, stethoscopes, pulse oximetry, look at oxygenation. As I said, I really like pulse oximetry and recovery of patients, but it's a noninvasive technique, tells us about the amount of, it tells about the amount of haemoglobin that is bound to those red blood cells. ECGs are always going to have on these patients as well.
We were going to tell us about heart rhythm. It would tell us heart rates. It doesn't tell us anything about cardiac output.
But if a patient's got an arrhythmia, that's probably going to affect cardiac output, or it may well affect cardiac output. We can see often blood pressure changes in those patients. So in terms of monitoring, we want to have really comprehensive monitoring, monitoring as much as we possibly can do.
I've said this already, these patients have got very little in terms of organ reserves. So we want to really keep a close eye on what's going on, identifying the alterations in normal physiological variables, ideally preoperatively and correct them. Thinking about hypothermia, really planning how we're going to keep these patients warm because they've got reduced central thermulatory re thermoregulatory mechanisms and also anaesthesia will reduce them further.
As we said, they've got that altered body composition, less muscle mass, less fat often in these patients, so they're going to get colder quicker. In terms of ventilation, we're going to look at things like respiratory rate. Certainly for me at our, at our hospital, it can be very different to, difficult to look at those patients' chests because they're covered completely in drapes.
So again, We could ideally look at chest excursions, we can look at re-breathing bags, breathing, our, our, our bags and our circuits, things like that. Use things like pulse oximeters, just be aware if we've got smaller patients or if they're in place for long periods of time. If those clips have got quite a strong spring on them, that they can often occlude the vessels and the tongue, particularly in smaller patients.
Capnography, I love, I can't do an entire lecture on capnography, but it's my favourite bit of monitoring equipment. It's the easiest way to assess ventilation to see how well those patients are getting rid of carbon dioxide. Carbon and, and our entitled CO2 that we measure with capnography can give us some information about cardiac output, because if your heart's not working properly, it's not gonna take blood sugar on so all those cells, pick it up and take it up to the lungs.
Also, we want to consider dead space. So again, we, if you can see this is a little image of any T tube adapter which has, got a, it's got a little connector, which you can attached to the sampling line. That's what this is here.
So that screws into the sampling line. If you have got a side stream, capnograph. So if you've got a Big, normally the big monitors, which really reduces down dead space, because other than that, you're having to have like extra connectors, things like that.
One of the things that we use regularly in our hospital, these heat moisture exchanges, and often those sampling lines will screw into those and we'll use those to get us another way of trying to stop these patients getting really cold under anaesthesia. Blood pressure, another really, really useful thing to monitoring these patients. We've got two techniques we can.
Use for indirect blood pressure monitoring. Direct blood pressure monitoring is the one where we place a catheter into an artery. Most of us are not going to do that.
For most of us that we're gonna use indirect techniques. We'll use either Dopplers or osciometrics. Dopplers are better for patients that are smaller, the more accurate in smaller patients.
Osciometrics are not accurate in small patients. So again, make sure you're using something appropriate, for that patient. Make sure we get the right size cuff, no matter what machine that we are using.
And think about what we want in blood pressure. Blood pressure is affected by cardiac output. We said these patients get all these changes, as well.
It's affected by heart rates. So again, if patients are really bradycardia, we can see changes in blood pressure, changes in volume status, so intravascular blood volume. So again, if we see these patients in with, you know, ruptured splenic masses bleeding into their abdomens, they are hypovolemic, we need to look at correcting that before we get into theatre or going away towards correcting that.
And it's also affected by what we call systemic vascular resistance, vasoconstriction, vasodilation. And a lot of our drugs we talked about, we use drugs because they avoid this from happening. As you said, our inhalation agents cause vasodilation, that will affect systemic vascular resistance, vasodilate.
Kind of that will cause a drop in your blood pressure. For me, these are my normals in kind of, particularly in a wake patient, but these are our normal ranges. And we want to make sure that we, we, we're not at the bottom level of that.
So, hypotension, low blood pressure, is defined as being a systolic blood pressure of less than 90 and mean arterial pressure less than 60. I don't wait until my values get to 90 or 60. If my, if I'm getting into the, like, 90s, like 100 with my systolic blood pressure, I'm gonna think about what I'm gonna do to correct that.
And again, this is all gonna be under veterinary direction as well. If my mean starts dropping towards 60, I think about why that is happening, what I can do about it. So when we do have patients where hypertension is an issue, as I said, one of the biggies is gonna be our, our inhalation agents.
So I think about can I turn my volatile agent down. As we said, It drops cardiac output, it causes vasodilation. So what I will do is see, can I turn my volatile down?
I'll discuss with the vets, can we add in more analgesia so I can hopefully turn it down, because that can often be an underlying cause. We often will give them a fluid bolus if that's not making any difference. So often we will bow in our vets will tell me to give that patient sort of 10 mL per kilo of a crystalloid and see what effect that has had.
We think about what's going on with the anaesthetic. Is there a reason why this hypertension is happening? So looking at all those factors, the other thing that we could think about doing, and often with geriatrics, I will, we will calculate these drugs preoperatively, in case we do see issues with hypertension, we'll use things like our inotropes, so things like dopamine or dibutamine, or we'll use vasopressors.
So inotropes kind of will increase heart rate and contractility. Vasopressors make those patients vasoconstrict. Yeah, so if we've got septic patients, they lose vasomotorone.
They've got bright mucous membranes, really fast pillar refill times because they're vasodilated everywhere. So we, these drugs will make those patients vasoconstrict and increase blood pressure that way. So as I said, we'll try and decrease anaesthesia.
We will think about using really good pain plans, looking at using local anaesthetics. So whether we're doing a regional block in a limb, whether it's a dent, so for dentals and, you know, geriatrics make up a big proportion of our patients having dental surgery. Lots of dental blocks.
There are lots of good articles out there. That can talk you through doing dental blocks. Nurses can legally do dental blocks.
So again, if anyone's really interested, I have articles that I've written that I can send out to you that teach you how to talk you through doing dental blocks. There are lots of places that are doing these courses now to teach you. How to use local regional anaesthesia.
It makes a massive difference. I'm sure there are a lot of you out there already doing this, but it's, those patients are happier. We don't need to have those, those, those inhalation agents as high.
These patients eat more quickly. Owners will comment on how much of a difference that it makes to these patients. So, think about what we can do.
As we said, can we add other agents in? Can we put them on fusions of things like lidocaine, ketamine, cautiously, remember, cardiac disease patients, but certainly our opioids. We use lots of fentanyl in our clinic.
Adding other things in, you know, I interviewed this paracetamol, you know, in patients where we can't use non-steroidals provided they've got normal liver function. So thinking about what we could use in those patients. I keep talking about this all the way through, but keeping these patients wrong is so, so important.
The minute we give these patients a pre-med, we change their behavioural responses. They're not gonna curl up and then we anaesthetize them. And if you were cold, those, if they were cold, these patients will curl up.
Yeah, they would shiver. That doesn't happen under anaesthesia. These patients have got a reduced metabolic rate by about 20 to 30%.
They've got altered hypothalamic function and that will also happen because of the anaesthetic agents we use and as we said, they don't have those effective responses. They don't shiver and they don't vasoconstrict when they're under anaesthesia, so they're likely to get colder quicker. Smaller patients much more prone to hypothermia, they've got that large surface to area to body mass ratio.
Also, we have the anaesthetic drug effects. A lot of our anaesthetic drugs cause vasodilation, which will make these patients lose heat more quickly. They've got reduced heat production, so they don't have normal muscle activity.
And we open these patients up, we put them on cold tables. Often it's, you know, quite cool in our theatres. So all of these increased losses.
So we want to really think about how we can minimise losses in these patients. So, circulating water blankets, I think a lot of us now we got things like bear huggers, these warm forced air blankets. And we do still use heat mats.
I, we have a rule that if we're using a heat mat, they have at least 2 layers of bedding underneath them for most patients. For patients that are underweight or if they're going to have a long procedure, we have 3 layers of bedding and we keep an eye on it. I'm always paranoid, always worried about thermal burns.
Our IV fluids, we will use, we will warm up, and we also use the little, fluid warmers. They probably don't make these patients help warm them up, but if I can stop them getting colder, I'm gonna do everything I can do. Lavage fluids, we will warm those as well.
And our scrub solutions we warm up as well. We're just really trying to stop these patients getting cold. Again, I say use caution, that's mainly related to heat mats and things like that.
So a lot of these things I've probably said already. We can look at things like passive warming. So just covering these patients up, blankets can reduce heat loss by 30%.
I realised it's not always possible during procedures, but if I can cover part of that patient, if I will do, and they do that because they create, they create a layer of trapped air that's warped. We want to think about active warming. So, as you said, heat mats, you know, warm, things like bear huggers, warming inspired gases.
So there's little heat moisture exchanges that sit between your anaesthetic circuit, and your, ET tube. Will kind of help to warm some of those inspired gases. If patients become hypothermic, that's gonna have effects on blood pressure.
It can cause hypertension. It's gonna affect peripheral circulation. These patients are going to have increased muscle activity and they're going to shiver postoperatively, and that has massive effects on the body as well.
So shivering will increase oxygen consumption by 200%. And again, these patients that have got these respiratory changes, we want to avoid that happening. And hypothermia can also affect ventilation as well.
So we really often underestimate what effect that it does have on patients. Analgesia, same applies as would apply in our, our adult patients. Put together that really good pain plan, as we said.
Opioids, not contraindicated, we can dose them, we can titrate into effect, really think about using local anaesthetic techniques and think about, as I said, I think about that pain plan. So I think about, you know, something happens, what am I gonna add in, you know, are we gonna run something as a continuous rate infusion? So as we said, things like lidocaine, things like fentanyl, we can put them on, you know, other opioid CRIs.
They can sometimes be quite difficult to administer and making sure we get the right dose, but opioids are great for things like this because we can really titrate into effect. Often, as we said, we're, we're, we're cautious, we're using some agents because we're not exactly sure about the pharmacokinetics, particularly in geriatric patients. We're not sure how those drugs are going to have an effect on the body.
Other analgesics, we can think about using non-steroidals. Again, a lot of these patients are probably on NSAIDs already because they're, they're, they're arthritic. So we will keep them on those other things that we can look at using are things like paracetamol or acetaminophen, if anyone's from the US.
We use this regularly in our geriatric patients. Provided they've got normal liver function, if we use an appropriate dose, it's fine. And I think it's becoming more and more commonly used now.
And we will use both the non-steroidal and paracetamol as well in patients. And as I said earlier on, really think about analgesia for, for procedures that we don't even think about as being painful, because in those geriatrics, they can still be very, very painful because we've manipulated joints, all those different things. In terms of recovery, constant attention, airway breathing circulation, think about keeping these patients warm, think about maintaining oxygenation in these patients, so supplementing oxygen if need be.
As I said, I really want to get them back up and moving around and back to normal and eating as early as early as I can. I want to get food back into these patients. And we may well consider to continue their fluids, post-operatively well do.
So, a lot of this, I said, really well padded bedding. Using things like orthopaedic mattresses, using foam mattresses, making sure we keep things as stressful as as possible and keep warming them until they've got a normal body temperature. As I said, shivering massively increases oxygen consumption for these patients and can contribute to hypoxemia as well.
In terms of recovery, I've mentioned this already, this post-operative cognitive dysfunction is well recognised in human medicine and in humans, it's seen as impaired memory, impaired con concentration, impaired language comprehension, impaired social integration as well. So we really see behavioural changes in, in humans, and often this can resolve with a period of time, but often it doesn't. We're not sure exactly why this happens, but we think it's probably due to things like cerebrovascular disease, hyper perfusion.
So hypertension under anaesthesia, we're not getting normal blood flow to, yes, we talk about kidneys, but the brain is really important as well. And geriatrics are much more susceptible to this. They don't have that plastic to the central nervous system.
And so we would get his alterations in neurotransmitter function, and we can see central nervous system inflammatory phenomenon as well. As we said, well recognised in humans, but really something that we want to really consider in our veterinary patients because you'd want your own animals to go home and be normal. Chronic pain, again, making sure these patients have good pain plans all the way through.
So, you know, Thinking about whether it's related to the procedure or whether it's related to underlying disease. So making sure we know if these patients are on long term pain relief. So thinking about things like chondrotectants, there's not an awful lot of evidence of them making any difference, but a lot of patients are on them, making sure that we continue with things like non-steroidal.
But think about adding other chronic pain medications and so a lot of our geriatric patients can be on things like non-steroidals, paracetamol, also things like gabapentin and amantadine. Amantadine is becoming increasingly common use and it's a really useful add in for patients that are really struggling. Talking to owners, particularly during that recovery period, short frequent walks, making sure they don't have to jump in or out of things, good bedding, so making sure they're doing all the things that we were doing postoperatively, make sure they continue, medications.
If these patients are hospitalised with us, I like to try and plan procedures together, so bundle things together, so they get a good time to sleep as well. Careful handling, careful with specific conditions. I've talked through this already.
And also consider the emotional effects of reduced exercise. So, if we, these owners aren't able to take their animals out as they would do normally, we want to think about how we can replace that. So that's using things like puzzle feeders and food toys and snuffle mats and all those things, really, really important.
We forget. The emotional effects of those animals not going out for a walk. So particularly dogs, how much does your dog love going for a walk?
If you take that away, that's probably the highlight of his day. Now, if you take that away, that really has emotional effects. We know this from humans, we know it's in, in, in, in, in that happens in veterinary patients as well.
So, really something I'm really keen on considering. TLC also really important to these patients. As we said, these geriatrics are frightened, they're confused, they're less able to compensate.
They have self-care deficits. So we need to think about what we need to do for our patients. So, so self deficit is doing things, we need to do things for those patients that they can't do.
So that's grooming them, helping them go outside, get, you know, using slings, things like slings to make sure they can posture properly, the toilets. So lots of things to consider. So for me, geriatrics really require careful constant consideration.
They've got these ageing organ systems, they're gonna have different considerations. They also have increased sensitivity to drugs, so we can get more complications if we don't really plan it and think about the effects those drugs can have. And that's my old Holly, my lovely old timer that I lost last year.
So if anyone's got any questions, I'm happy to take them now. I think the plan is for me to have a two-minute break while I drink some fluids and, yeah, rehydrate. Hi, Louise.
Thank you so much for your webinar presentation. Your presentations are always jam packed with lots of practical information, so I'm sure attendees found it very useful. Just before we go to any questions for Louise, the webinar vet team really appreciate your feedback.
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So, question time for this first presentation. Louise, I was thinking at the start of your presentation, thinking about geriatric pets generally, do you think we should be inviting our geriatric pets for more regular health checks, perhaps more frequently than the annual booster to ask questions that might give us clues about You know, signs of age-related diseases and discuss how we might alleviate them or slow down the progression. Then, sorry, you did mention that coming into the practise can be quite stressful for some geriatric pets, you know, as you mentioned about losing their sight.
So then I thought a compromise might be, a survey that's completed by owners. So then you're getting information, that might give you these subtle clues, but you're not putting your pets under too much stress if they find it stressful coming into the practise. Yeah, I think it's a really, really difficult one because it is a stra you know, even You know, I work in a hospital, and a few of us have been, sorry, with my microphone.
A few of us have been really, really unfortunate when our clinic first opened in that there were kind of 3 members of staff and our dogs were diagnosed with lymphoma. And one of them was a boxer, and he hated coming in, and he hated coming in so much. And I think A lot of us, you know, until you have your own animal, go through, you know, a major disease process, I think we often really underestimate the impact that coming into hospitals have on patients.
Or until you see it happening with another member of staff, I think it's easy to kind of be like, Oh, owners. But actually, it is a really stressful situation. So, I think, you know, even if owners just can ring in and speak to someone over the phone about anything that that animal is struggling with, I'm not necessarily saying that we're gonna go out and do home visits all the time.
But even if, you know, even if it's possible, just talking to owners about things that they can do, you know, owners ringing up and saying, you know, he's doing this, he's, you know, maybe not getting around as, as easily, you know, it, you know, talking to owners, is there a way that we can, you know, can we send them some information about, you know, particularly things like, you know, I'm a big fan of, though, you know, I mentioned, you know, if we take away exercising patients, the impact that will have on them. And we live in a world where, you know, talking about frozen stuffed kongs and talking about puzzle feeders and all that is normal to us. Owners don't necessarily know that they exist, you know, talking about things like snuffle mats and all those things.
So just making sure that owners are aware of the impact of things like reduced exercise and how we can look to replacing that. We know that it's a big issue, humans that have chronic pain. Can become very depressed.
And we think animals are probably the same as well, related to that. And that's because the area of your brain associated with pain and the area of the brain associated with depression come from the same limbic system, and the two kind of very closely related. So I think if we can, like, really make it, make it so that owners can communicate easily with us, as we said, we could do surveys, we can look at, you know, sending things like there's, chronic, when we look at chronic pain, there's a, A scoring system called the Helsinki pain scoring system that we could get owners to complete at home and send in, can probably create an electronic version that they can send back to us, just to make them aware.
Of, of what changes that we can see in patients with things like, you know, chronic pain. For other, other issues, we're more likely to have to see those patients in the hospital. But no, I completely agree, trying to avoid it as much as if it's very stressful for the animal, as much as you can.
But ultimately getting owners to bring those animals in regularly, so that isn't quite such a stressful situation. So it becomes quite normal for them. Yeah.
That's great. Thank you very much, Louise. We haven't had any further questions submitted, so we will just have, do you want 2 minutes or we start at 5 past?
Yeah, we can do. I can drink. I could drink more Ribena then.
Yeah. So, we'll give Louise a bit of time to enjoy her Ribena. And, we'll start the session again at 5:09.
Like, I should have I should have said it was a mimosa or a book's favourite? That made me sound much more glamorous. OK, thanks, Louise, and we'll speak to you again in a minute.