All patients deserve quality care while hospitalized. Patients recovering from surgery have special needs to maintain their comfort. This includes both the immediate postoperative period of anesthesia recovery and any further hospitalization required until discharged. Postoperative pain control is essential to healing and patient well-being. Pain control is covered in Chapter 2 on Preoperative Planning. Patients must be directly monitored while recovering from anesthesia. After stopping the flow of anesthetic gas, patients are maintained on an appropriate rate of oxygen flow until they are breathing well on their own. They are never left alone while an endotracheal tube is in place. Once a patient shows signs of consciousness, it is appropriate to deflate the endotracheal tube cuff and extubate the patient. Some patients may become very restless and begin thrashing during this time. It is important to assess the patient’s pain level to determine if pain is causing the behavior. If pain is noted, appropriate pain medications are provided to maintain analgesia. If pain does not appear to be causing the patient distress, it is possible for the patient to be negatively reacting to anesthetic or analgesic medications. Many of these drugs can cause dysphoria. A tranquilizer may be indicated for these patients to calm them down while the drugs are dissipating from the body. Even after the endotracheal tube is removed, patients recovering from surgery must be closely watched. (This is also a great time to trim toenails. Clients appreciate this extra benefit.) Patients’ body temperature is monitored for changes. Hypothermia is very common, especially during long surgical procedures. The intraoperative and postoperative use of circulating hot water blankets, hot air warming units, blankets, towels, and so on lessens the incidence of hypothermia. Special care is taken when using microwaveable discs/packs or warm fluid bags. These products must be wrapped in a towel before applying to the patient to avoid contact burns. Patients are warmed to a body temperature of 99 °F before removing supplemental heating sources. Some patients, particularly cats, may develop hyperthermia after surgery. This appears to be an abnormal reaction to certain narcotic medications (Posner et al. 2007;.Niedfeldt and Robertson 2006) These patients are cooled by housing in a stainless steel cage with no bedding, applying cool, wet towels over the back or in the groin area, and by using fans. The patient is continuously monitored until a normal temperature is achieved. While recovering from anesthesia, patients may not have good control of their bladder or bowels. Keeping the patient and cage clean are imperative to avoid contamination of the surgery site and to maintain patient comfort. Once a patient is fully awake and able to stand (assuming it is expected to stand after surgery), it is safe to return the patient to its normal hospital cage. Dogs are walked, prior to returning to their cage or run, to urinate and defecate. Orthopedic and neurologic patients may need the assistance of a sling, towel, or blanket to aid their ambulation. Patients must not be allowed to slip and fall after any procedure. Patients become stressed when not in their home environment and surrounded by their family. They are exposed to new smells, sounds, and handlers. Providing them with a comfortable and safe area, away from noise and hospital traffic, calms their fears and aids in healing. Many forms of bedding and housing are available to maximize patient care and comfort. Blankets and towels provide warmth and padding from cage and run floors. They must always be laundered and sanitized between patients. Monitor bedding frequently for patient soiling and change bedding as needed. Patients must never be allowed to reside in their urine, feces, or other body fluids. When soiled bedding is found, it is imperative to also check and clean the patient. Urine and feces left on the hair and skin may cause scalding and wound contamination. Treat patients as one would want one‘s own pet taken care of. Foam rubber pads provide extra comfort for recumbent patients as well as those recovering from surgery. (Figure 7.1) To avoid cross-contamination between patients, the foam rubber is enclosed in an impermeable material. These pads can be custom made in sizes that partially or completely cover the floors of cages and runs. They are also made in a variety of thicknesses depending upon the depth of foam rubber interior. The pads are covered with waterproof material and should be cleaned and disinfected between patients. They are monitored for patient chewing or damage. If damaged, prompt repair is important to prevent patient ingestion from chewing the internal foam rubber as well as contamination and wetting of this material. Figure 7.1 Cage pads provide comfortable conditions for patients. They must be impermeable and easy to disinfect. Rubber and plastic mats come in a variety of sizes and configurations. Commercially available mats are made in sizes specifically made for different brands of cages and runs or available by the roll – cut in clinic to custom sizes. They come ribbed or with circular holes to allow drainage (Figure 7.2). While they aid in keeping a patient out of urine, some urine may still be trapped between the mat and the patient. Close patient monitoring reduces this problem. These mats also provide traction for patients needing extra footing. However, they are generally hard plastic or rubber and provide minimal padding. Figure 7.2 Perforated cage mats allow urine and other fluids to pass away from the patient; however they are not soft and provide minimal padding. Yoga and other commercially available mats are generally thin providing minimal padding. However, they are great for providing extra traction for patients in cages. They, also, are beneficial for performing patient exams – both for patient and technician/veterinarian comfort. Thin mats provide stability for standing exams. They provide padding for personnel standing, kneeling, or sitting while examining or restraining a patient. A wide variety of beds is commercially available for added patient comfort. These include covered corrugated foam rubber to help prevent pressure sores. Four legged “hammock” type beds made of plastic mesh aid in keeping recumbent patients comfortable, allow urine flow, provide cooling, and air circulation (Figure 7.3). Figure 7.3 Hammock beds allow fluids to pass away from the patient, are soft and help to cool a patient with air circulating beneath the bed. Air and water mattresses are especially beneficial for preventing skin ulcerations. However, they are susceptible to leakage caused by patients’ nails and teeth. They also do not allow urine to flow away from the patient. These mattresses provide the best patient comfort when covered with a blanket or towel. If any of these types of beds are not available, rotating a patient frequently helps to alleviate sores in recumbent patients. Cages are lined with paper to provide patient traction and to absorb urine and spilled water. They also provide cold protection from the metal, plastic, or fiberglass cage floor. Commercially available cage paper can be ordered to custom fit cages. It does not cause staining as with newspaper and absorbs bodily fluids. While it is resourceful to recycle newspaper as cage lining, the ink can transfer to patients, especially when the paper gets wet. Newspaper, also, becomes smelly when moist. Plastic litter pans and covers, boxes, and crates provide stressed patients with comfort and help to keep small patients warm. Cats, especially, are anxious when hospitalized. Arranging a place for them to hide may help to calm them. Extra blankets or towels allow for burrowing. The top of a covered litter pan placed on a blanket is a great place for a cat to hide (Figure 7.4). It can easily be lifted up to allow patient access. Simply covering the front of the cage with a towel can give a kitty a feeling of safety by lessening visual stimulation. Figure 7.4 Boxes, crates, and litter pan covers provide a great secure “hiding place” for feline patients. Blanket-lined boxes and large litter pans, either, upright or on their side give cats and small dogs a compact, warm-resting area. The sides of the box/pan must be low enough to allow the patient to move in and out. Caution is taken to monitor the patient for box chewing to avoid gastrointestinal obstruction. Crates of assorted size and configuration provide a safe, warm, and closed environment for small dogs and cats. They also provide ease of transporting the patient around the hospital. If a patient arrives at the clinic with a crate, housing the patient in its own crate while in a cage is helpful. This is especially useful for calming stressed patients by providing them with the “smell of home.” Placed in the patient’s cage, the crate’s door is left open for patient access. Crates are inspected and cleaned as needed to avoid post-op contamination and soiling. Housing cats in upper cages helps to relieve their stress. However, this is not practical with fractious patients – cats or dogs. These patients should always be housed in lower or mid-height cages to allow easier patient access and to protect personnel from injury. Patients in middle height cages can be coaxed onto a gurney at the same height level. Fractious and fearful patients are easiest to manage in low cages and runs. Patients will often walk out of an open cage or run door if they do not feel threatened. Minimal personnel in the area help the patient to feel less intimidated. When leaving an open lower cage or run door open, the surrounding kennel doors must be secure to avoid patient escape. When drastic removal measures are needed, e.g., rabies pole, the only safe area for accessing a patient is a lower cage or run. Feline facial pheromones sprayed on blankets or as atomizers in rooms help to soothe cat patients. It calms and relaxes them during hospitalization and during venous catheterization (Carney et al. 2012). Canine pheromones as atomizers in kennels may calm anxious dogs. Patients are continually monitored for eating behavior both before and after surgery. Maintaining them on their home diet helps to encourage eating and reduces dietary upset from a change in the type of food. Trauma, surgery, pain, and the stress of hospitalization may lead to anorexia, as does the use of narcotics and anti-inflammatory medications. The body has a higher metabolic demand as it is recovering from surgery, infections, burns, and tumors (Fossum 2007). Long-term hospitalization accompanied with anorexia leads to malnutrition. The use of feeding tubes is advisable in these patients. Clients can be taught how to maintain the tube at home and provide parenteral nutrition. Stress-related diarrhea might occur in surgical patients. Providing them with a bland but nutritional diet may aid in reducing diarrhea. Homemade diets of boiled hamburger or chicken and rice are bland but often enticing to the patient. Many commercially available diets provide excellent nutrition to fit a variety of metabolic conditions. Following surgery, especially involving the spinal cord, patients may develop the inability to urinate. Many techniques are available for emptying a bladder. While in the hospital, a patient may have an indwelling catheter or repeated catheterization episodes. Care is taken to maintain sterile technique and minimize the risk of introducing bacterial cystitis. Catheterization of a male dog is much easier than a female dog and dogs are easier than cats. Using a catheter of the appropriate size for the patient provides the best results while limiting urethral trauma. Highly pliable red rubber and Foley catheters decrease the chance of bladder and urethral perforation when compared to stiff polypropylene catheters. Indwelling catheters are sutured in place. Attached to an administration set and empty intravenous fluid bag or urine collection bag creates a closed system for urine collection. Patients are monitored closely to keep from chewing the catheter and often need an Elizabethan collar. Bladder expression is tailored to the individual patients. Cats and small dogs have easily palpable bladders that can be held in one hand. Grasping the bladder in one hand and providing gentle but firm compression may achieve the desired results. Never attempt to express the bladder of a patient with a potential urethral stricture. Struggling to express the bladder in these patients may result in a bladder rupture. For larger patients, a two-handed technique is required. The patient may be laying in lateral recumbency or standing with support. Using the flat surfaces of the hand, not the tips of the fingers, palpate the bladder. While isolating the urinary bladder, the hands are pushed together, while also pushing toward the patient’s back. This traps the bladder between the hands and the back, thus allowing only one path for the urine – out the urethra. Patients with bladder control are difficult if not impossible to express due to their sphincter control. Animals recovering from different types of intervertebral disc disease may have a neurogenic bladder – lacking bladder control. This includes under or over activity of the detrusor muscle and the urinary sphincter depending on the site of the protruding disc. Patients with overly distended bladders may leak urine leading to misdiagnosis of their ability or inability to urinate. Unless a full voluntary stream of urine is observed, the presumption is the patient is experiencing overflow urination. Palpating the bladder’s size, and/or imaging the bladder, confirms this assumption. Patients with overflow have a distended bladder. This must be addressed immediately to avoid permanent damage to the bladder musculature. External coaptation devices include external skeletal fixators (ESF), bandages, casts, splints, and slings. Most of these apparatus serve a specific purpose in orthopedic patient care. However, soft tissue patients require bandages for wound protection, active, and passive drainage control and for support. For example, a non-healing full thickness wound of the hock may heal better with a splint support that decreases bending and stretching of the wound while allowing wound healing. Figures 7.5 and 7.6 show an example of an Irish wolfhound with a nonhealing pressure sore treated with a custom-made orthotic splint. Multiple primary closure attempts were performed in this patient. However, due to the location of the wound, several incidences of dehiscence occurred. The wound eventually closed by second intention after protection and support of the orthotic splint and topical therapy. Figure 7.5 Wolfhound is shown with a nonhealing granulating wound on the lateral side of the foot. The patient laying on the wound and the motion within the foot decreased the ability to heal the wound. (Robert Hardie, University of Wisconsin Veterinary Care. Madison, WI. Reproduced with permission from Robert Hardie.) Figure 7.6 The same patient as seen in Figure 7.5 with an orthotic device to allow wound care, stop motion at the wound site and protect patient from lying on the wound. (Robert Hardie, University of Wisconsin Veterinary Care. Madison, WI. Reproduced with permission from Robert Hardie.) External coaptation serve the following functions: To be effective in stabilizing a fracture, the entire bone must be supported. To do this requires the joint proximal and distal to the fracture to be immobilized. This is easily accomplished with injuries to the tibia/fibula by supporting the hock and the stifle and correspondingly fractures of the radius/ulna require immobilization of the carpus and elbow. Humerus and femur fractures require a spica splint for temporary stabilization. A spica bandage involves applying the bandage completely up the leg and incorporating the trunk. Splint material, extended from toes to body midline, is added to the bandage to keep the shoulder/hip from moving. If this type of bandage is impossible to apply, it is best to leave femur and humerus fractures with no protection. Coaptation that does not include the joint “above and below” the fracture may terminate at a fracture site thus creating a fulcrum and putting more pressure on the injury (Bohling 2012). Bandages, splints, and casts provide temporary support. Applied to a fracture prior to internal fixation, they control pain by limiting the movement of the fractured bones. Further soft tissue damage is decreased from any sharp fracture ends that may cut or puncture muscles, veins, arteries, and skin. Stabilization with a bandage or splint may keep a closed fracture from becoming open with the bones edges protruding through the skin. Provided as first aid; bandages, splints, and casts limit further trauma while allowing for safe transportation of the patient to a treatment facility. External coaptation delivers supplemental support when applied after internal fixation for fracture or tendon repair. ESF add stability and control rotational forces of intramedullary pin fracture repair. Acute tendon tear and laceration repair requires additional reinforcement to prevent bending and stretching as the tendon heals. Following many soft tissue and orthopedic procedures, postoperative bandages, applied for 24–48 hours, may control pain and swelling while keeping the incision clean and absorbing postoperative drainage. Recent studies show no reduction in swelling by bandaging patients after Tibial Plateau Leveling Osteotomy (TPLO) surgery (Unis et al. 2010). Casts, splints, and external skeletal fixation devices offer primary support of certain fractures and chronic tendon strains. A young animal with a nondisplaced fracture of the radius and an intact ulna may heal very well with a splint or cast. Greenstick or incomplete fractures also require less support than more serious injuries. However, petite dogs with a forelimb fracture often do not heal with only external coaptation (Welch et al. 1997). Patients with chronic strains of the calcaneal (Achilles) tendon or tendon repair benefit from long-term support via a bandage/splint combination or a custom made orthotic splint or brace (Figure 7.7). The orthotic can be made with a hinge to allow the ability to increase its range of motion over time. Figure 7.7 A custom-created orthotic with a hinge for treating a patient with a calcaneal tendon strain. The range of motion of the hinge is increased over time to allow more freedom of movement as the patient heals. (James T. Lewellen, University of Wisconsin Health Orthotics, Middleton, WI. Reproduced with permission from James T. Lewellen.) Not all orthopedic patients require external coaptation. Internal fixation of a fracture or ligament tear provides strong stabilization. They, most often, do not require any additional support other than a soft-padded bandage for 24 hours to control postoperative swelling. The veterinarian’s decision to apply long-term external coaptation has several considerations. Very long-term wound care may benefit from a custom designed splint for support, ease of removal, and minimization of bandage sores. All bandages require the same “ingredients.” As discussed with open wound management, these include the primary wound cover, a padding layer, a compressive layer, and a protective layer (Figure 7.8). Figure 7.8 Anatomy of a bandage: (L–R) primary wound cover (oil emulsion gauze), tape stirrups (foreground), and tongue blade to keep stirrups separated, cast padding, elastic gauze (foreground), protective layer.
Chapter 7
Postoperative Care
Anesthesia recovery
Housing
Bedding
Pads
Perforated mats
Other mats
Other bedding
Cage papers
Boxes/hiding spots
Cage height
Pheromones
Nutritional support
Urinary bladder care
Bandages
External coaptation concepts (Piermattei et al. 2006)
Types of support
Temporary support
Supplemental support
Primary support
Considerations
Anatomy of a bandage
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