10 ways to be a rock star in the OR

Here are simple suggestions to help greatly improve your anesthesia protocols and their safety

Regularly change the soda lime per the manufacturer’s recommendations.
Regularly change the soda lime per the manufacturer’s recommendations.
Photos courtesy EMD

Because it has become very safe overall, anesthesia tends to be considered routine by some colleagues and nurses. However, there is a big difference between decreasing mortality and reducing morbidity. Clearly, different clinics do things differently.

Some do everything by the book—their team follows solid patient-support protocols. Animals are extubated, standing, and with normal vitals shortly after surgery is completed and as if it never happened. Meanwhile, there are other clinics that ignore body temperature and blood pressure, and over-anesthetize patients. Here are 10 ways to be a rock star in the OR.

1) Water

Do you know what your receptionists and nurses tell clients? “No food or water after 8 p.m./10 p.m./midnight” is a saying that is passed from generation to generation. Preventing water intake for eight to 12 hours can cause mild dehydration in a healthy patient and more severe dehydration in older or renal-impaired patients. Adequate hydration is critical for a successful anesthesia and surgery. It is preferable to allow water access until the morning of surgery. This is especially true in patients with metabolic disorders such as diabetes.

2) Machine

Leak-test your anesthesia machine every day and have it tested yearly to ensure your vaporizer is administering the amount of gas you think you are providing. Regularly change the soda lime per the manufacturer’s recommendations. And remember, protocols depend greatly on the provider.

Waiting for color change has been shown not to be an appropriate method of ensuring your anesthesia machine is operating properly. A change in color is not at all universal and can be misleading—it all comes down to the brand you use.

3) Pre-medicate

Pre-medicating your patients lowers their stress preoperatively, resulting in lower induction drug dosages and inhalant anesthetic percentages. This helps their vitals stay closer to normal and wake up more smoothly. Your nurses will thank you when placing the IV catheter as well, since the patient will be calm and mellow. However, it is important to understand and anticipate the side effects of “pre-meds.” You and your team should be prepared to notice dysphoria after giving benzodiazepines, bradycardia with alpha-2 agonists and opioids, and hypotension with acepromazine. Balanced anesthesia can mitigate these side effects.

4) Protocols

We can’t claim every patient is different, yet use a cookie-cutter protocol. One of the wonders of veterinary medicine is that we constantly discover better ways to do what we do. Make sure your protocols are current. Not only that, update them regularly.

Anesthetic protocols should be tailored to species, breed, temperament, type of procedure, age, body composition, and health status. Consider enrolling the help of a board-certified anesthesiologist to update your protocols.

5) Emergency

Have your emergency drugs calculated (and printed) before you even induce the patient. Excel spreadsheets make it very easy: all you have to do is enter the patient’s weight. Online calculators are also available (for examples, see bit.ly/3fsLBbK). Sure, you will not need it 99 percent of the time. But when you do, seconds count and it can mean the difference between saving a patient and losing one.

6) Oxygen

Even if they are not a brachycephalic and cardiac patient, pre-oxygenate animals before surgery. As long as it doesn’t stress them out unnecessarily, all patients should be oxygenated for five minutes prior to induction using a mask or anesthesia hose. Pre-oxygenation increases the body’s oxygen reserves, delaying the onset of hemoglobin desaturation, should your patient become apneic. Pre-oxygenation helps lower the risk of hypoxia during induction. This is especially helpful if you anticipate intubation might be difficult.

7) Hypothermia

Preventing hypothermia is no different than preventing pain. It’s much easier when you start early in the process. This means warming efforts should begin during surgical preparation, not once your patient is in the OR, or worse, back in a cage. The patient’s temperature may start dropping as soon as premedication or induction drugs are given, so hypothermia prevention should begin at that time. This can be as simple as covering the patient with a blanket. Some practices place a warm-air device in the cage for use after surgery. By then, however, you’re playing defense, not offense.

Some safety valves open once the airway pressure exceeds a certain limit, helping to eliminate the risk of damaging the patient’s lungs (barotrauma) even if the pop-off valve is mistakenly left closed during a procedure, after using a mechanical ventilator, or during machine leak testing.
Some safety valves open once the airway pressure exceeds a certain limit, helping to eliminate the risk of damaging the patient’s lungs (barotrauma) even if the pop-off valve is mistakenly left closed during a procedure, after using a mechanical ventilator, or during machine leak testing.

Intraoperatively, monitor your patient’s temperature regularly and make adjustments accordingly. Warm air devices, warm water blankets, and heated tables are all great options.

Just make sure you are following the manufacturer’s maintenance and usage guidelines. Always provide a barrier between the skin and the heat source. (For more on this topic, see my column in the March 2020 issue or at bit.ly/2ywNOC4.)

If you don’t have a heating unit, you can still help. Patients’ paws can be covered with bubble wrap, socks, or foil. You can dedicate some fluid bags to use as fluid warmers. The IV line can be coiled around a warm fluid bag to warm up IV fluids, which are otherwise at room temperature. Cover all parts of your patient not in the sterile field, including the head, with towels or blankets. Never place the patient on a cold prep table, surgery table, or X-ray table without first covering it with a blanket or a towel.

8) Valve (part 1)

Consider getting pop-off occlusion valves, a.k.a pop-off valve restrictors, for each of your anesthesia machines. Without them, your anesthesia nurse needs to close the pop-off valve before giving a breath.

Closing the valve might need to be done dozens of times during a long procedure. Unfortunately, every once in a while, someone forgets to reopen the valve, which can cause serious lung damage to the patient.

With a safety pop-off valve, you completely eliminate that risk. All your nurse has to do it push the button on the valve to give a breath without closing the pop-off valve. As soon as the button is released, the pressure goes down and your patient is safe again. Such valves are made by multiple suppliers.

9) Valve (part 2)

The need to ensure patient safety has led to the development of one proprietary safety valve that opens once the airway pressure exceeds approximately 28 cm H2O, eliminating the risk of damaging the patient’s lungs (barotrauma) even if the pop-off valve is mistakenly left closed during a procedure, after using a mechanical ventilator, or during machine leak-testing.

10) Monitoring

If you aren’t already doing this, use an anesthesia monitoring log. Vitals should be recorded every five to 10 minutes. This allows you to notice trends and correct as needed. In addition, manual monitoring should be performed regularly. Don’t merely rely on technology when it comes to the safety of your patient. The anesthesia log should then become part of the patient’s medical record.

None of the above suggestions is complicated. Each can and should be implemented at any practice. By doing so, you will greatly improve your anesthesia protocols and their safety.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified, is a board-certified veterinary surgeon and serial entrepreneur whose traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his website at DrPhilZeltzman.com. He also is cofounder of Veterinary Financial Summit, an online community and conference dedicated to personal and practice finance (vetfinancialsummit.com). AJ Debiasse, a technician in Blairstown, N.J., contributed to this article.

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