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Reducing anaesthetic risk in the perioperative period – a team approach

How can we reduce anaesthetic risk in the perioperative period? A team approach

“By failing to prepare, you are preparing to fail”
Benjamin Franklin

Introduction

A thorough understanding of anaesthesia, analgesia & patient monitoring is essential when caring for our patients in the perioperative period. Adverse events, complications and mistakes do happen, but by planning thoroughly together and ensuring everyone understands all factors surrounding each patient these risks can be reduced.

Registered Veterinary Nurses (RVNs) in the UK are responsible for monitoring patients under the direction of the Veterinary Surgeon (VS). However, we have a huge responsibility which involves efficiently detecting problems and complications, communicating effectively and undertaking the appropriate inventions under the direction of the VS. 

Planning & Preparation is key!

Good communication, thorough planning and checklists will reduce the risk to our patients. This combination slows us down and ensures vital steps are not missed & tasks are done correctly. In addition, it may help to reduce stress within the team as everyone involved knows what to do if a complication or adverse event occurs.

Practice life can be busy and often we are pushed for time however setting up properly should not be rushed. A few ways our patients can come to harm is shown in Figure A. All of these possible complications & errors can be prevented if we use checklists and have systems of work in place to help reduce errors.

The World Health Organisation (WHO) have published many evidence-based papers reporting that when checklists were implemented in hospitals globally, the incidences of human error, complications and patient deaths were significantly reduced (Haynes et al, 2009). As a profession we have taken hold of this wonderful evidence and now checklists are used within our profession too. The Royal College of Veterinary Surgeons (RCVS) recommend the use of checklist as part of good clinical governance within the practice standards scheme (PSS).

The Association of Veterinary Anaesthetists (AVA) have collaborated with Jurox UK to create free, downloadable checklists and implementation manual to support teams get on board.

Download your AVA Checklist here

Download the AVA Checklist Guidance Manual here

Part of clinical governance involves the completion of clinical forms and documents – this should be comprehensive. When completing pre, peri and post anaesthetic monitoring forms we should ensure we write every detail and it should read like a step-by-step account of what happened. By doing this ensures that if there are any complications or adverse events, or a patient death occurs there is a clear, written account of what did, or did not, take place. This falls back in with checklists again, if it was recorded that the said task was completed it should have been undertaken. Checklists should be viewed as more than a ‘tick box’ exercise as it emphasises the key points that should be discussed and the tasks which should always been undertaken. RCVS Knowledge, a charity partner of the RCVS, has lots of great checklists and resources available to help support veterinary professionals in practice. In addition, they have provided significant event audit (SEA) templates to help support you and your teams when complications occur or if you do have a patient death.

 https://bit.ly/34OjpuM 

“Teamwork makes the dreamwork” …. cliché but essential!

The discussion the VS & RVN (or whole anaesthesia/surgical team) have surrounding the patient from start to finish is especially important. What are the comorbidities? What is significant about this patient? What possible complications may occur and what are the interventions if X occurs? What drugs & fluids are most appropriate, and which are not, and why? Is support available from other team members if required?

Let’s put into context If we’re discussing a……

Brachycephalic bitch spay; How might we manage this patients airway? Is suction available if the patient regurgitates? Has this patient been appropriately starved? What type of drugs are most appropriate and what additional drugs might be needed? What level of patient warming is appropriate? How should we position this patient? What is the plan if we encounter bradycardia from these breeds having increased vagal tone? Do we have team members available to closely monitor this patient on recovery? Do we have oxygen provision available in kennels if required? Are the owners aware of the increased level of risk?

Next up let’s consider a Flat Coat Retriever with a haemoabdomen due to suspected splenic pathology; IV access? One IV catheter or two? What fluid therapy is required? Crystalloids? Hypertonic saline? Colloids? Do we have blood products? Are they in date? Drug therapy to address hypotension? What would this patient’s normal circulating volume be? If we need to transfuse the patient what volume of blood would we need? What analgesic techniques can be used? What drugs might be given to treat arrythmias? What patient warming techniques can be used? Is the crash box ready? Do we have ‘do not resuscitate’ status?

By discussing patients together, you will create a spider’s web of considerations and hopefully reduce risk to your patient by changing protocols and patient management for each patient, every time.

We are much more likely to make a mistake with our drug or fluid calculations if we are under pressure which is why we should try to do this in advance where possible. Hypoventilation, hypothermia and hypotension are frequently reported in anaesthetised patients, so these are key areas to monitor for and plan ahead to try and prevent.

Understanding drugs

Due to the RCVS code of professional conduct RVNs are not legally allowed to prescribe drugs. Despite this I feel it is important for RVNs to have a good understanding of the effects a drug has on a patient and what to expect, and not expect. There are so many drugs in practice and it is difficult to remember which does what so talking about it with your team beforehand will reduce stress & help you manage your patient more effectively.

For example, if a patient is premedicated with acepromazine the desirable effect is mild sedation & anxiolysis however the one of the undesirable effects is vasodilation which will make the patient more prone to hypothermia and hypotension. The duration of acepromazine is 6 – 8 hours so patients should be kept warm and have their blood pressure and temperature monitored closely. On the flip side if they are premedicated with medetomidine the desired effects are analgesia & sedation which are dose dependent, but the sedative effects are often more profound than acepromazine. We also know they are likely to develop bradycardia and reflex hypertension due to vasoconstriction – this is an expected physiological response. The bradycardia should be interpreted relative to what their normal resting heart rate was prior to drug administration, as the rate often reduces by ¼ to ½ the normal rate. Blood pressure should also be closely monitored. If bradycardia with concurrent hypotension is encountered the VS should be notified and they may advise the administration of atipamezole (the antagonist of medetomidine) prior to the administration of anticholinergics. Towards the end of medetomidine’s duration of action there is the chance for subsequent hypotension as the vasoconstrictive effects wear off and the patient’s heart rate may not necessarily increase back up to the normal rate. This may be tolerated in healthy patients therefore medetomidine’s use in larger doses is usually limited to use in healthy patients. Not knowing that alpha-2’s agonists such as medetomidine have this physiological effect could be very confusing and in addition could lead to the incorrect intervention being performed. From understanding the expected desirable & also the undesirable effects we can action plan, in advance.

YAY for ASA!

Last year Jurox created a veterinary patient-specific American Society of Anaesthesiologists (ASA) physical status scale. This is a scale which has been adapted from the human anaesthesia world. The system classifies patients I – V depending on their physical status, comorbities and associated risk.

For example;

  • I - Normal healthy patient with NO systemic disease (healthy young cat castrate)
  • II - Patient with mild systemic disease which is compensating (epileptic dog patient stable on treatment)
  • III - Patient with severe systemic disease which is NOT a constant threat to life (cat with renal disease)
  • IV - Patient with severe systemic disease which IS a constant threat to life (bitch pyometra)
  • V - Moribund / terminally ill patient which is not expected to survive without surgery (Dog with a Gastric dilatation & volvulus)

This ASA guide for veterinary patients can be downloaded here

A view by Portier et al, 2018 showed that the ASA scoring system was a useful prognostic tool in guiding clinicians regarding risk of death and the risk of patients developing hypothermia. One thing to mention here is that the ASA physical status scale does not provide any guidelines as to what should and should not be given, or how patients are managed but it does encourage discussion between professionals to plan ahead thoroughly to reduce risk to patients.

Close patient monitoring is always essential and the relationship between the VS & RVN is pivotal to ensure communication is always thorough and efficient

The patient

Every patient should have a full clinical examination performed prior to any drugs being administered – to assess what is ‘normal’ or ‘abnormal’ for them prior to premedication. Ultimately, we are assessing their vital body systems to ensure they can compensate for the physiological effects analgesia & anaesthesia drugs may have. Performing these checks will also help us assess if what we detect later is ‘normal’ for that patient & expected, or something unexpected and something to worry about – like the presence of a heart murmur, for example. Auscultating the patient’s thorax alongside peripheral pulse assessment is essential in helping us to assess their cardiovascular health prior to anaesthesia. If any murmurs, arrhythmias or pulse deficits are found these should be noted and communicated. Often this examination is undertaken by the member of staff admitting the patient however this should also be undertaken by those who are assigned to treat and monitor the patient during the perioperative period too.

When reading the patients clinical history, we should be noting what medications the patient may be receiving as this could change what drugs should and should not be given – again these are not decisions to be made by RVNs but are relevant to flag up to our VS. Some types of medications may increase the likelihood of adverse events under anaesthesia to occur – for example feline patients receiving daily hypertension medication may be more prone to perioperative hypotension, patients on long term oral opiates for arthritis may be more or less sensitive to the effects of injectable opiates, and patients on long term non-steroidal anti-inflammatories could be accidentally overdosed with these drugs potentially leading to renal damage and gastrointestinal complications.  

The final point to make on this section is to check if the patient has had an anaesthetic in the past. Are there any comments as to how the anaesthetic went? Were they any complications? Was the patient slow to recover? Did they have a period of severe hypotension which required intervention? Did the owner comment on admission that there were any issues post-procedure last time? If problems were noted last time it’s worth ensuring it’s flagged up and clearly written on the patients forms so that the VS can decide if an alternative protocol be used, or whether the patient should be managed or monitored differently.  

Routine procedure? Perhaps! …. but try never to view any patient as ‘routine’

A ‘higher risk’ patient who many of us may encounter daily is the geriatric cat dental. Whilst the procedure itself may be ‘routine’ and age is not necessarily a disease, it is likely some of these patients will have underlying diagnosed (or undiagnosed!) pre-existing conditions. These can be conditions such as hyperthyroidism, hypertension, or renal disease. At my practice all patients undergoing general anaesthesia are audited and most of our feline dental patients are either ASA II or III. Bearing this in mind these patients may be less able to compensate with the adverse effects of our anaesthesia drugs. Therefore, multimodal analgesia (to include local anaesthetic dental blocks) is essential to ensure low levels of volatile agent can be used for maintenance. This is because our volatile inhalation agents cause dose dependent cardiorespiratory depression and vasodilation which will adversely affect our patient. The lower the percentage used the lower the adverse effects you should encounter.

Dental patients are particularly prone to hypothermia due to getting wet, often having a poor body condition score and the length of the procedure. Active warming should be discussed and implemented from induction, if not from the onset of premedication. Airway management and close care and attention is especially important. The risk of tracheal trauma is greater in patients that will be moved and rotated, especially if cuffed endotracheal tubes are being used. Team members should be mindful when manoeuvring the patient’s head or turning over. Patients should be disconnected from their breathing system when turned over to prevent the ETT twisting and cork screwing in the trachea which can cause inflammation, trauma or tears. The larynx may also become very inflamed which may result on laryngospasm and airway obstruction on recovery once extubated. Dental patients, in my opinion are at greater risk of post-operative complications so watch them very closely!

Don’t relax just yet - the recovery period!

The highest risk phase for anaesthetic related death is during the first three hours of recovery (Brodbelt et al, 2008). How many of you have a ‘sigh of relief’ as you turn off the vapouriser dial? This is not the time to relax as the most time-critical period is about to begin. Interestingly the study highlighted that a healthy cat was twice as likely compared to a healthy dog to have an anaesthetic related death. Why was this? Short procedure & lack of perceived risk? Poor airway management? No IV access unlike longer procedures? Again, think about who gets more monitoring post operatively in your practice – the dog castrate, or the cat castrate? Only when you start looking at evidence do you realise just why close monitoring of ALL patients is imperative no matter what the procedure as things can and do go wrong. Intravenous access is a must in every patient, every time (where physically possible!) to ensure emergency drugs can be administered efficiently if needed.

Ensuring there are dedicated members of the nursing team available to specifically monitor patients is essential. In a busy recovery ward the use of timers can be useful to remind you to check a patient if you have multiple patients recovering at similar times. Patients should be observed continuously until they have been extubated, their gag reflex has returned, and they can lift their head. Patients that are higher risk such as brachycephalics, ASA IV – V patients should have continuous monitoring until you & your VS are satisfied that they are maintaining their airway, they are conscious & their vitals are stable. 

To conclude

Thankfully in practice anaesthetic deaths and complications are relatively uncommon, however it is a good idea to monitor and audit any adverse events or complications. From this I would encourage you to discuss what is happening as a team and together change patient monitoring and management protocols to reduce the chances of it happening again. Here is an example of what an ‘anaesthesia audit’ looks like which focused on adverse events encountered at my practice & the changes and interventions that were implemented as result:

https://bit.ly/2VpcK7e (Louise Northway RCVS Knowledge Champion audit 2019)

I really believe that checklists make a huge difference and should be encouraged and utilised in every veterinary practice. Look at the vast amount of resources that are already available to help support you in practice, or better still why not create your own checklists and patient management protocols?

Getting into the habit of discussing the patient with your VS & wider team will help you trouble shoot possible complications and adverse events – you may even be able to prevent them occurring in the first place! Team discussions encourage a positive learning environment where your team’s previous experiences will help improve the level of care your patient might receive.

Finally remember that patient monitoring is pivotal every step of the way and the monitoring should continue long after the vaporiser dial is turned off!

Article by
Lou Northway
VNCertECC NCert(Anaesth) RVN

Lou qualified as a Veterinary Nurse in 2009. 

She currently works in a large, busy, primary care practice as clinical nurse lead where she undertakes clinical governance procedures, sets and reviews clinical nursing protocols alongside regular nursing duties.

Lou's main interests in practice are OOH, emergency & critical care, anaesthesia & analgesia, and quality improvement. Since qualifying she has completed two additional certificates in ECC and anaesthesia which she feels has  helped her to enjoy her job even more.

Alongside working in practice Lou is a member of the British Veterinary Nursing Association Council. Her aspirations are to work on RVN retention and empowerment, career progression and development & be a positive voice for the profession.  In 2018 Lou launched an online social media page 'Lou The Vet Nurse' where she shares her hints and tips with fellow nurses and technicians. In addition she also lectures internationally to nurses in her areas of interest which she thoroughly enjoys.  

Social media: @louthevetnurse
Website www.louthevetnurse.com

Originally published: Wednesday, 9th September 2020
Last updated: Wednesday, 16th September 2020

References

Anaesthesia records and checklists. [Online] Available at: https://ava.eu.com/wp-content/... 19/04/2020].

Brodbelt D.C., Blissett K.J., Hammond R.A., Neath P.J., Young L.E., Pfeiffer D.U. and Wood J.L.N. (2008). The risk of death: The Confidential Enquiry into Perioperative Small Animal Fatalities. Vet Anaesth Analg. 35: 365-373

Divya, J., Ridhima, S. & Reddy, S., 2018. WHO safe surgery checklist: Barriers to universal acceptance. Journal of Anaesthesiology Clinical Pharmacology, 34(1): 7-10.

Duke-Novakovski T., de Vries M. & Seymour C. (eds) (2016). BSAVA Manual of Canine and Feline Anaesthesia & Analgesia. 3rd Edition. British Small Animal Veterinary Association, Gloucester, UK

Haynes, A., Weiser, T. & Berry, W., 2009. A surgical safety checklist to reduce morbidity and mortality in a global population. The New England Journal of Medicine, 360(5): 491-499.

Ludders, M. & McMillan, M., 2017. Errors in Veterinary Anesthesia. 1st ed. Chichester, UK: John Wiley & Sons.

McMillan, M. & Darcy, H., 2016. Adverse event surveillance in small animal anaesthesia: an intervention-based, voluntary reporting audit. Veterinary Anaesthesia & Analgesia, 43(2): 128-135.

Portier, k. & Ida, K., 2018. The ASA Physical Status Classification: What Is the Evidence for Recommending Its Use in Veterinary Anesthesia?—A Systematic Review. Frontiers in Veterinary science, 204(5)

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Buprenorphine: it’s not all static in rabbits

Opioids are well known for causing gastrointestinal stasis in mammalian species. This recent paper examined the effects of a single high dose of buprenorphine on the rabbit gastrointestinal tract using non-invasive imaging techniques.

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Caesarean Section Survival Guide. Part 1: Physiology & Pre-anaesthetic Considerations.

In the first instalment of this 2-part review Karen examines the physiological changes that occur during pregnancy and how those adjustments can affect the selection of anaesthetic protocols for the increasingly common Caesarean section.

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No leeway for the spay: A comparison between methadone and buprenorphine for perioperative analgesia in dogs undergoing ovariohysterectomy.

This recent paper compares post-operative pain scores and requirement for rescue analgesia following premedication with methadone or buprenorphine, in combination with acepromazine or medetomidine, in 80 bitches undergoing ovariohysterectomy.

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Cardiac arrest - the human factor

Cardiac arrest in dogs and cats is, thankfully, relatively rare. However, when it does happen it can have devastating consequences for the animal, owner and the veterinary team. This study examined the common causalities leading up to a cardiac arrest with the aim of changing protocols to improve outcomes.

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Are you Using Safety Checklists in your Practice?

In this article, Carl focuses on the benefits of introducing a safety checklist in practice to reduce patient morbidity, mortality and to improve communication between members of the veterinary team. The article contains links to the AVA safety checklist as well as a link to a customisable list that you can adapt to your practice needs. 

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The Big Chill - Temperature Management in Sedated and Anaesthetised Patients

The effects of hypothermia are very far reaching throughout the peri-anaesthetic process. In this article, James takes us through the interesting mechanisms of body cooling and warming, the clinical relevance of hypothermia and what we can do to prevent it.

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Keeping the Finger on the Pulse -  Nuances in CV Monitoring

All patients are exposed to the risks associated with general anaesthesia. Continuously monitoring anaesthetised patients maximises patients safety and wellbeing. In this article, Dan takes us through the common monitoring techniques that provide information about the cardiovascular status of your patient. 

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Effect of Maropitant on Isoflurane Requirements & Postoperative Nausea & Vomiting

Despite being widely recognized in humans, postoperative nausea and vomiting (PONV), and the role of maropitant in reducing inhalational anaesthetic requirements have been poorly documented in dogs. This recent study evaluates PONV and isoflurane requirements after maropitant administration during routine ovariectomy in bitches.

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New! Alfaxan® Multidose Now Available

We are happy to announce we have enhanced our anaesthesia and analgesia portfolio with the introduction of Alfaxan®Multidose for dogs, cats and pet rabbits.

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Sevoflurane requirement in dogs premedicated with medetomidine and butorphanol

Little information is available about the effect that different doses of medetomidine and butorphanol may have when using sevoflurane for maintenance of anaesthesia in dogs. This recent study evaluates heart rate and median sevoflurane concentration required at different dose rates.

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Capnography II - What happened to the elephants? A summary of abnormal traces

In this second article of the capnography series, James provides a guide to a few of the most common traces that you will encounter during surgery. Scroll to the end of the article to download a printable capnography cheatsheet. 

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Pain, what a Pain! (Part 2) – Practical Tips On How To Perform Dental Nerve Blocks In Companion Animal Practice

In this second article of the Pain, what a Pain! series, Dan takes us through the LRA techniques associated with dental and oral surgery. In this article, you will find practical tips and pictures on common dental nerve blocks as well as safety concerns to consider.

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​Peri-anaesthetic mortality and nonfatal gastrointestinal complications in pet rabbits

This recent retrospective study looks at the cases of 185 pet rabbits admitted for sedation or general anaesthetic and evaluates the incidence and risk factors contributing to peri-anaesthetic mortality and gastrointestinal complications.

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Pain, what a Pain! How Locoregional Anaesthesia can Improve the Outcome and Welfare of Veterinary Patients (Part 1)

In this first article out of a series of two, Dan takes us through an introduction and practical tips for appropriate local anaesthesia delivery. Find out why these anaesthesia techniques, that are well recognised in human medicine, have seen an increase in popularity in veterinary medicine over the recent years

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Perspectives on Premeds – Opioids

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This second article aims to provide a refresher on opioids.

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Effects of Dexmedetomidine with Different Opioid Combinations in Dogs

Read the highlights of a recently published research paper that evaluates cardiorespiratory, sedative and antinociceptive effects of dexmedetomidine alone and in combination with morphine, methadone, meperidine, butorphanol, nalbuphine and tramadol. 

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Preoxygenation Study Highlights

This study evaluates the effectiveness of two methods of preoxygenation in healthy yet sedated dogs and the impact of these methods on time taken to reach a predetermined haemoglobin desaturation point (haemoglobin saturation (SpO2) of 90%) during an experimentally induced period of apnoea.

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Capnography – Not Just a Load of Hot Air

Capnography is the measurement of inhaled and exhaled carbon dioxide (CO2) concentration. The graphical illustration of CO2 within respired gases versus times is known as the capnogram.

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Perspectives on Premeds – Alpha-2 Agonists

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This first article aims to provide a refresher on α2 agonists.

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Alfaxan - now licensed for use in pet rabbits

Jurox Animal Health is delighted to announce that Alfaxan is now licensed for cats, dogs and pet rabbits. This is an exciting advance and could change the way rabbits are anaesthetised in the U.K.

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