Anesthesia: It Ain’t Over Till It’s Over
Anesthesia: It Ain’t Over Till It’s OverAnesthesia: It Ain’t Over Till It’s OverMonday, February 1, 201002-01-2010By Phil Zeltzman, DVM, Dipl. ACVScutting-edge
David Brodbelt, a British board-certified anesthesiologist, undertook a massive thesis known in the anesthesia world as CEPSAF.1 In the rest of the world, it is called the Confidential Enquiry into Perioperative Small Animal Fatalities. After the thesis was published, some more data has been published in various journals2.
Our colleague looked at anesthesia records of more than 98,000 dogs and 79,000 cats (OK, and more than 8,000 rabbits), from more than 100 practices. Obviously, this represents unusually huge numbers for a veterinary study.
Anesthetic-related death was defined as perioperative death within 48 hours of termination of anesthesia. Countless interesting conclusions can be drawn from the study, and I would like to focus on one specific point.
Let’s start with a pop quiz: would you say that most perianesthetic deaths occur during induction, surgery or recovery?
The correct answer is that over half of the perianesthetic deaths occurred within 3 hours of termination of anesthesia.
It is difficult to know exactly why these patients died; only 10 percent had necropsies. Granted, some of these patients may have been very sick animals who may have “decompensated.” In many cases, it may be lack of monitoring while the patients were still recovering.
In other words, the study suggests that recovering patients should be monitored at least as closely as anesthetized patients.
One conclusion from the authors is, “If closer monitoring and management of patients in this early postoperative period were instituted, then mortality might be reduced3.
So what could you do in your practice to decrease this risk?
As in many other endeavors, the first step is awareness. An open discussion should be started between doctors and technicians, for example during a staff meeting.
It is important to avoid becoming complacent. Just because a patient is out of the OR doesn’t mean that we’re out of the woods. We’ve all heard that “Bulldogs shouldn’t be extubated until they are walking.” But what about other breeds?
Walking away from a patient after extubation may be a risky proposition. At the very least, the patient should get frequent TPRs. Gum color and capillary refill time should also be assessed. Heart and lungs should be auscultated. Monitoring might also include ECGs, blood pressure readings and pulse oximetry.
- There cannot be a set protocol for all patients. Protocols need to be altered based on the patient’s needs: additional pain medications, a heat source to fight hypothermia, bladder expression, more IV fluids, less IV fluids, repositioning, TLC, blood products.
How can you accomplish this when there are so many other things to do?
One solution may be to have a dedicated technician for recovery patients if you have a busy surgery schedule. In fact, this should include all anesthetic procedures, including dentals. Even if you don’t have a big case load, the technician in charge of the anesthesia could remain in charge of the patient until it is deemed safely recovered.
The CEPSAF study is truly exceptional by its size and comprehensiveness. I wish we had more large-scale veterinary studies such as this one. Statistics would be immensely more reliable.
Ultimately, the greatest surgery, performed by the greatest surgeon, is only great if the patient goes back home. As they say, “There are routine surgeries, but there is no routine anesthesia.”
3. DC Brodbelt et al. “Risk factors for anaesthetic-related death in cats: results from the confidential enquiry into perioperative small animal fatalities (CEPSAF).” Br J Anaesth. 2007, Vol 99, N 5, 617-623.