High-risk patients: Supportive care, monitoring, and postoperative care (Proceedings)

Supportive care is based on recognition of patients needs

Focused monitoring and patient evaluation leads to individualized care.

• Appropriate patient evaluation provides for the recognition of anesthetic risks and anesthetic concerns for that specific patient and procedure. "Problem-based" anesthetic management is the framework for individualized patient care.

What "anesthetic concerns" have you identified for this patient?

• "100 things are missed due to not looking for every 1 thing missed due to not knowing".

• Preanesthetic physical examination and laboratory analyses - individualized "minimum data base" based on risk

• diagnostic imaging radiographs, contrast studies, CT, MRI, ultrasonography, scintigraphy, etc.

• other directed testing

ASA physical status categories

• American Society of Anesthesiologists (ASA)

• ASA I - excellent anesthetic risk

• ASA II - good anesthetic risk

• ASA III - fair anesthetic risk

• ASA IV - poor anesthetic risk

• ASA V - guarded anesthetic risk

• additional "Emergency" designation (x)-E

Ventilatory complications

• Airway obstruction

• Inadequate Delivery of Oxygen

• Hypoventilation

• Inadequate Ventilation, Apnea

• Hyperventilation: Tachypnea or panting

• Irregular patterns of ventilation

• All anesthetics are respiratory depressants!

• Anesthetic overdose: Relative or Absolute

• Direct depression of central respiratory centers

• Secondary to circulatory depression

• Specific drug actions

Hypoventilation requires patient support

Endotracheal intubation, ventilatory support by IPPV manual or mechanical ventilation based on patient monitoring, evaluate and address the underlying problem.

Hyperventilation and/or panting are less common, but may reflect hyperthermia, pain, or occur as a side-effect of specific drugs. Control of body temperature, management of pain, and control of ventilation may be necessary.

Support for Circulatory compromise

Hypotension is a common problem due to hemorrhage and/or vasodilatation. Circulatory support is largely based on fluid therapy, including crystalloids, and colloids. A variety of fluids are now available, with blood substitutes serving and important need. Vaso-active agents help support blood pressure, cardiac function, and tissue perfusion.

Temperature support

Hypothermia is an almost universal problem in small animal anesthesia and many areas of critical care. Risks of thermal support have been great with older heating strategies. The forced warm air systems offer a new method and much better means of providing thermal support.

Delayed recovery from anesthesia

• Anesthetic overdose

• Inadequate elimination or metabolism

• Hypothermia

• Debilitation

• Neurological deterioration

Management of delayed recovery

• Physiological support

• "SOP" - monitor, evaluate, diagnose, treat

• Facilitate elimination or metabolism

• Reversal of anesthetic drugs only when appropriate

Metabolic and endocrine support is needed by some at-risk patients due to immaturity or disease.

Inadequate glycogen storage or availability

Adrenal insufficiency

Excessive physiological demands

References

1. Handbook of Veterinary Anesthesia, Third Edition, by William W. Muir, III, and John A.E. Hubbell, Skarda, Bednarski, 2000, Mosby-Year Book, Inc.

2. Manual of Small Animal Anesthesia, Second Edition, by R. R. Paddleford (ed.), 1999, Churchill Livingston.

3. Veterinary Anesthesia and Pain Management Secrets, S. A. Greene, (ed.), Hanley and Belfus, Philadelphia, 2002.

4. Pain Management for the Small Animal Practitioner, by W. J. Tranquilli, K. A. Grimm and L. A. Lamont, 2000, Newton NewMedia.

5. Essentials of Small Animal Anesthesia, by J. C. Thurmon, W. J. Tranquilli, G. J. Benson, (editors), 1999, Lippincott, Williams and Wilkins.

6. Manual of Small Animal Anaesthesia and Analgesia, C. Seymour and R. Gleed (eds.), British Small Animal Veterinary Association, 1999.