Two important parts of any surgical procedure’s successful outcome is the surgery itself and the anesthesia/analgesia that ensures patient safety and comfort. However, there are many other factors to ensure a patient’s comfort: both physically and emotionally. They will be listed and discussed in this article by category.
It is well known in human medicine genetic variants play a role in pain sensitivity, as does pre-existing chronic pain conditions. What about those breeds you cannot give a subcutaneous injection to without the dog vocalizing (think huskies and Shelties)?
It is also well known animals with prior severe pain events can have plastic changes made to their spinal cord that increases sensitivity to pain, be it a prior acute traumatic event or a chronic pain, such as osteoarthritis. We need to step back, look at these patients, and ask ourselves if a one-size-fits-all approach is appropriate for them
Cage size is an often-overlooked important factor. This becomes more important for animals spending more than an hour or two in their cages, and it becomes extremely important for those animals spending several days in the clinic. All animals need to be able to stretch their full body length without encountering the sides of the cage.
Cats have additional needs, as they are also asked to eliminate within their cage space, making it necessary for a sizeable separation from sleeping, eating, and litterbox areas. Research has shown a two-foot distance forming a triangle from food to bed to litter box should be considered; not everything on top of each other.
This can sometimes be accomplished by building a “loft” within the cage: This utilizes less floor space and additionally gives the cats more places to hide.
Dogs should be given the opportunity to take a walk, not only for purposes of elimination, but for the chance to stretch muscles, do a full body shake, and get the mental stimulation dogs, in particular, get when going on a walk.
Exposure to other animals should be as limited as possible. Dogs should be set up in cages or runs that are side-by-side and not facing each other whenever possible. Anxiety levels can ramp up if one of the dogs is barking or posturing aggressively. Increased anxiety has been shown to heighten the pain response.
Cats should be kept in the same cage configuration, but in a separate room from dogs.
Pheromone therapy for both cats and dogs, such as Feliway and Adaptil, should be utilized as needed.
For either dogs or cats, this should not be social isolation; animals from the same family should be hospitalized together if appropriate. Also, interaction with people in the clinic can be reassuring to most animals.
ER and recovery cages are often kept in a common area, with people and animals coming and going or passing through as a steady stream. If this describes your space, set up a video camera or smart phone in a cage, pointing out to mimic an animal’s point of view. Do it for half an hour and then replay to see what they see and hear. It can be a real eye-opener, but more importantly a tool to make changes at your clinic. These extraneous noises and sights from the clinic should be kept to a minimum. Consider the everyday noises of phones ringing, cupboards and drawers being open and closed, staff members “yukking it up” about what they did last Saturday night, and doors slamming shut.
Moving and positioning anesthetized patients is often an afterthought. The two primary problems usually involve too-large dogs for table and transport, and surgical positioning.
You may have a gurney for moving large dogs, but it may not be large enough for some of your largest patients.
Anticipation for moving these large dogs should be a consideration in scheduling procedures to make sure there is enough staff available to safely move (for both the patient and the movers) the patient to and from procedures while anesthetized.
When it comes to the surgery itself, for both dogs and cats, there is a tendency to over-restrain during surgery. Sometimes these positions can exacerbate existing conditions or create new ones. The question I always ask myself, “Am I restraining to get optimal access to the surgical site, or is there an issue with pain control causing unnecessary patient movement?” Imagine yourself being forced into one of the two following positions by restraint for an hour or more; many of these patients, especially geriatric, are more painful the next day because of their positioning than because of the surgery itself.
Warmth is important during surgical procedures, but certain drugs, such as alpha-2s, can prohibit shivering. It is important to provide a warm environment during recovery. This can be as complicated as special warming cages and warming devices, or as simple as sweaters from the pet store “dollar bin,” and towels and blankets run through a dryer on the hot setting.
Nausea is an often-ignored issue for our patients. In one human survey after a surgical procedure, patients reported nausea was a more noxious experience than the post-operative pain. It is reasonable to assume the same is true for our patients.
Take a look at the analgesic drugs you are using; some drugs such as morphine and hydromorphone almost always cause vomiting. Other analgesic drugs like dexmedetomidine, fentanyl, and methadone less so. We need to consider not only nausea around the anesthetic event, but also the ride in. Oral maropitant the night before the procedure, continuing with injectable maropitant can help alleviate these feelings of nausea. Ondansetron is another anti-nausea medication that can be given by injection.
Another good reason for preventing nausea is the importance of eating during surgical recovery. Eating a meal and getting proper nutrition helps with recovery and healing of the surgical patient. Do not hesitate to use drugs like mirtazapine or Entyce to stimulate appetite.
Anxiety, as mentioned previously, can increase pain levels, as well as making a patient hard to interact with. Utilizing tools from Fear Free and Cat Friendly guidelines can make the caregiver more aware of even subtle signs of anxiety. The various environmental and pharmaceutical interventions are too vast to include in this article, but anesthesia compatible interventions are available and can be found at either of these organizations.
The patient after discharge
Finally, make sure owners are able to provide the post-op care and medications we ask them to do. Do they have the time? Do they have the physical ability? Is the dog too large or does the owner have a disability that would prevent them from following through? Every discharge should include demonstrations of both medication administration (it may seem simple to us but we do it all of the time) and anything physical needing to be done, whether it is a bandage change, how to apply ice packs, or how to help their animal move or stand up.
Michael Petty, DVM, is a graduate of the veterinary school at Michigan State University. As the owner of Arbor Pointe Veterinary Hospital and the Animal Pain Center in Canton, Michigan, he has devoted his professional life to the care and well-being of animals, especially in the area of pain management. Dr. Petty is the past president of the International Veterinary Academy of Pain Management. A frequent speaker and consultant, he has published articles in veterinary journals and serves in an advisory capacity to several pharmaceutical companies on topics of pain management. Petty has been the investigator/veterinarian in 12 FDA pilot and pivotal studies for pain management products. He has lectured both nationally and internationally on pain management topics.
I want to give a special thanks to Dr. Sheilah Robertson who provided many of the photos used in this article.