Minimally invasive ways to bring Fear Free to veterinary surgery

October 11, 2018

Robin Downing, DVM, DAAPM, DACVSMR, CVPP, CCRP, CVA, MS in Clinical Bioethics, is a founder and past-president of the International Veterinary Academy of Pain Management. She owns Windsor Veterinary Clinic and The Downing Center for Animal Pain Management in Windsor, Colorado. 

Tips for reducing fear, anxiety and stress in your surgical patients (and the people who own them).

Shutterstock.comFear Free medicine isn't limited to the exam room. The same principles and measures that reduce fear, anxiety and stress (FAS) in regular checkups can also calm surgery patients. Here are some ways to apply the Fear Free approach both before and after surgery.

Before surgery

Put some prep in your steps. Get everything ready for an upcoming surgery patient the day or night before the procedure. In our practice, we stock a basket with the things we'll need. This includes:

the syringe and blood tubes we need for preop blood work

the IV catheter and adaptor plug

the IV fluid bag and IV infusion set

sterile saline flushes.

We also enter the patient's data into our electrocardiogram (ECG) database. All of this upfront work reduces the time we'll need to get the patient ready for surgery the following day, which lessens the amount of time the patient has to become stressed by waiting around for something to happen.

Divide and conquer FAS. Be sure to keep dog and cat patients in separate spaces or wards with appropriate pheromones while awaiting surgery.

We are a small practice, so when we have a cat present for anesthesia and surgery, we allow it to stay in our cats-only exam room with natural light, iCalmCat music playing, a Feliway Classic pheromone diffuser and a clean litter pan. We allow feline patients to remain in that space until we're ready to premedicate them, which means we perform their examination, draw their blood, and perform their preop ECG in that room. This approach has been a real game-changer for the cats we serve.

Don't wait to medicate. Don't be afraid to provide the owner with a single dose of gabapentin to give the patient the morning of the surgery with a small amount of Pill Pocket or other delivery food. Such a small amount of food will not create unnecessary risk for the patient, and that single dose of gabapentin won't interfere with a balanced anesthesia protocol. 

We premedicate with a very small dose of acepromazine combined with hydromorphone, and we induce with propofol and midazolam. The owner-given gabapentin reduces the amount of medication we need to induce, but the big payoff lies in the fact that it dramatically reduces the patient's FAS, meaning the animal doesn't have to deal with an adrenaline dump-no unnecessary fight-or-flight response. This makes the entire anesthesia event safer for the pet by preventing an out-off-control sympathetic nervous system.

Set the mood. Keep your preop area tranquil by using pheromone diffusers-Feliway for cats and Adaptil for dogs. Use your “inside voices,” play iCalmPet music (or quiet music of any kind), and keep extraneous noise to a minimum. Be sure to move slowly and deliberately whenever handling patients.

Give ‘em the warm fuzzies. A cold patient is a stressed patient, and because animals can lose a tremendous amount of body heat between premedication and induction, we need to prevent it from happening.

One of our favorite solutions is a simple one. We use a towel warmer (like the kind you'd find in a spa) so we can have hot towels or fleeces at the ready. After delivering the premedication, we drape the front of the patient's cage with a warm towel and place another warm towel in the cage with them. Bigger dogs should not be put back in a run after receiving their premedication. Keep them in a cage large enough for them, even if it's smaller than you would normally use to house them for any length of time. You have to provide a smaller space if you're going to contain their body heat.

After surgery

Bring the heat. Keeping patients warm is an important part of reducing stress (and thus FAS) before, during and after surgery. Provide heat support during the procedure, and then as the patient emerges from anesthesia, wrap it in a warm towel.

Try a little tenderness. Consider recruiting a volunteer who can specifically support anesthesia patients. We have a “TLC nurse” who comes in on our anesthesia days. Once patients are transported to their recovery “bedrooms,” our TLC nurse sits with them, wrapping them in warm towels, petting them and speaking softly as they awaken. As a result, our patients are able to gently emerge from anesthesia, and then they simply slip back into a restful sleep postop-the very best thing that can happen for them.

Provide scents of peace. Awakening to familiar smells is meaningful for patients who rely on their noses to evaluate their environments, so have owners provide a t-shirt or towel that smells like home to use in recovery.

It's also important to avoid making your patients “nose blind” (i.e. they can no longer smell or process the scents in their environment) by using harsh disinfectants in your patient areas. Because smell is so meaningful to animals, nose-blind pets can become disoriented and frightened. The Rescue line of accelerated hydrogen peroxide cleaning products provides appropriate disinfection without causing pets to become disoriented.

Clients need comfort too

You are of course well aware that the patients aren't the only ones who experience FAS. Give comfort to clients by explaining your hospital's Fear Free approach. Show them where their beloved pets will spend their time while in your care, and be sure to point out all of the little things you provide to keep patients calm and comfortable (e.g. hot towels, pheromones, music). Lastly, it's important to provide ways for the client to stay in touch with your team so that they can get updates whenever necessary and put a stop to FAS caused by waiting and the unknown.

Dr. Robin Downing, who holds a master's degree in clinical bioethics, is a diplomate of the Academy of Integrative Pain Management, a diplomate of the American College of Veterinary Sports Medicine and Rehabilitation, a certified veterinary pain practitioner, a certified canine rehabilitation practitioner, and hospital director at the Downing Center for Animal Pain Management in Windsor, Colorado.