10 mistakes to avoid after surgery

The postop period is the riskiest part of the surgical process

E-collars are extremely important after surgery to prevent pets from licking or chewing their incision, as well as keeping them from chewing out their IV catheter or damaging their IV line.

Just because surgery is over doesn’t mean that your care of the patient should be, too. Most people (clients included) mistakenly believe that the riskiest part of the entire surgical process is the procedure or the anesthesia. In fact, it’s the postop period. The following are 10 suggestions to help decrease postop complications.

1. Monitor

More than half of perianesthetic deaths occur within 3 hours of the end of anesthesia, according to the study, “Confidential Enquiry into Perioperative Small Animal Fatalities,” by David Brodbelt, MA, VetMB, Ph.D., DVA, DECVA, MRCVS. A technician should monitor the patient for postop complications so they can intervene should an emergency arise. Parameters to track regularly include temperature, pulse, respiration, mucus membranes, capillary refill time, IV fluid rate, and more. Continue to auscultate the heart and lungs.

If the patient is still very sedated or not coming around after a normal period, leave the monitor hooked up to ensure that vitals are not going into dangerous territory. If it’s difficult for you to bring an ECG or measure blood pressure, at least consider monitoring pulse oximetry.

There cannot be a set protocol for all patients. Protocols must be adjusted 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, PCV, blood products, etc.

2. Extubation

Depending on the patient/procedure performed, you may need to keep the endotracheal tube in place longer than usual. Brachycephalic patents and patients recovering from upper airway surgery have an increased risk of aspiration (or suffocation) if the tube is pulled too early.

Ensure patients are awake and aware enough. People make up all kinds of guidelines, such as the “3 swallows rule” or the “5 swallows rule” to decide when to remove the ET tube. Yet, in real life, patients can swallow multiple times before they are aware enough to be extubated.

3. E-collars

E-collars are extremely important after surgery to prevent the pet from licking or chewing the incision, as well as preventing them from chewing out their IV catheter or damaging their IV line. Ideally, the E-collar should be placed before extubation to make it less stressful for patient and technician alike.

4. Pain

Rather than sticking blindly to a cookbook recipe (every 4 hours, every 6 hours, every 8 hours), pain medications should be given based on the patient’s needs. Track the patient’s pain score in order to tailor pain management.

5. Voodoo

Some colleagues may not use certain drugs because of perceived complications or reasons that borderline on voodoo. Actual examples come to mind: “buprenorphine causes oral ulcers in cats,” “hydromorphone should be banned in dogs because of its potential side effects,” or “XYZ drug kills patients.”

Having one bad experience with a particular drug does not neccessarily mean you shouldn’t try to use that particular medication again. Superstition has no place in the field of veterinary medicine.

Overall, managing pain could still be greatly improved in our patients. There are multiple safe and effective drugs that one can use beyond butorphanol.

6. Chemo

I was stunned when the owner of a busy small animal practice once told me, “We don’t believe in chemo in this practice.” So he never recommended follow-up chemo, and his associates weren’t allowed to do so, either. Meanwhile, oncologists administer chemo drugs every day, and they seem to have a pretty good track record. Of course, like any drug, chemo drugs can cause side effects, but pets typically respond to them with fewer complications than people.

Pet owners should know all the reasonable options available to them when it comes to treating their pet.

7. Rads

Don’t forget to take postop radiographs after a cystotomy and foreign body surgery. Things can migrate in surprising ways, and certainly stones and foreign bodies can be left behind. Therefore, it is critical to take rads to confirm that all stones or all foreign bodies have been removed. Postop rads after a cystotomy are now considered standard of care.

8. Discharge

Discharge instructions should be in writing and tailored to each patient to ensure owner compliance. Review them thoroughly with clients, line by line, to ensure that they know what to do, what not to do, and what complications to look out for. Include information for an after-hours emergency clinic just in case there are complications.

9. Follow-ups

Owners must clearly understand the timing and cost of follow-up appointments: suture removal, follow up rads with or without sedation, follow up visits with a doctor, physical therapy, or future medications that may be needed (for example, based on biopsy or culture results), etc.

10. Callbacks

Ideally, all surgery clients should be called the day after discharge. It shows that you truly care, and it’s a great time to answer questions and alleviate concerns. You know what is normal versus abnormal—most clients do not.

Picking up their pet after surgery likely feels like a whirlwind, so clients likely don’t remember most of what was said during the discharge. Just because they keep nodding doesn’t mean that they truly understand what you’re saying and what they’re supposed to do.

A common question is, “Should the pet be in the room during the discharge?” We would argue that the pet should not be present, as it is one more source of distraction. If you need to demonstrate something on the actual patient, then do it after going over the paperwork.

Even though you feel that you have been thorough and you sent home written discharge instructions, that doesn’t mean clients have a clue what they’re supposed to do.

We know the questions by heart: “Why won’t Kiki eat?” “Why won’t Kiki drink?” “Why hasn’t Kiki pooped yet?” “Is that discharge from the incision a normal thing?” “Why is he still groggy?” “He doesn’t seem in pain, can I stop giving the pain medications?”

Maybe we’re heard those questions hundreds of times, but for your clients, it may be the first time.

So do the right thing, reassure your clients, and patiently help them follow your instructions. The outcome of your surgery and the health of your patient depend on it.

Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. Visit his websites at DrPhilZeltzman.com and VeterinariansInParadise.com.

Nikki Schneck, a technician near Pottsville, Pa., and Kelly Serfas, a certified veterinary technician in Bethlehem, Pa., contributed to this article.

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