How should practitioners prepare when faced with administering anesthesia to patients with more complex medical issues?
Grimm: It's all about management of risk, and monitoring is the key to risk management in anesthesia. Occasionally there will be
two diseases present in the same patient, which normally would be managed completely opposite to each other if either presented
by itself. For instance, consider heart disease and kidney disease. One of the things that puts stress on the kidneys is hypovolemia.
But if the animal has bad heart disease, and you give too much fluid to prevent hypovolemia, then congestive heart failure
When you get caught in those situations, you have to come up with a plan that gives you several options. If you start to have
problems with blood pressure, then you have to re-evaluate whether you want to give more fluid or add inotropic medications
to help support myocardial contractility.
If the patient is doing well, then you might want to stop or slow fluid administration. Close monitoring, like ECG, constant
use of pulse oximetry; intermittent arterial blood pressure; arterial blood gases to monitor oxygenation, ventilation and
lactate production; and auscultation of the lungs to make sure that you aren't developing pulmonary edema, are essential.
Older patients generally do well as long as you adjust drug dosages, account for any concurrent diseases and monitor appropriately.
One consideration with older patients is that, over time, they can use up their reserve organ function. For example, as patients
age they may lose the extra nephron function they had when they were young. Liver function probably is decreasing with age,
too. You have less margin for error, but if you monitor them carefully problems can be caught quickly, and you can intervene
to reduce further cellular injury and loss of organ function.
Obese patients are commonly anesthetized for routine procedures, and they usually do quite well if managed appropriately.
Where they really become tough to deal with is during the recovery process while weaning them off oxygen and putting them
back on room air. They're still under the depressive effects of the anesthetic drugs and the opioids we often use for pre-anesthetics,
so close monitoring of ventilation and oxygenation is important.
Again, it all boils down to good monitoring and early intervention if you detect a problem.
While they're anesthetized, patients with upper-airway diseases such as tracheal collapse, laryngeal paralysis and brachycephalic
airway syndrome usually do well because they are getting oxygen, and you have a protected airway.
There may be some challenge at induction if you have a hard time with intubation. And most of the time they extubate well
but, sometimes, after you pull the tube out, you can't get them to oxygenate. Then you have to put an airway back in and figure
out another plan. Of course at that point you may be talking tracheostomy or other surgical intervention, but often a slow,
carefully monitored recovery will allow extubation without emergency surgery.
What advice can you give practitioners, especially when it comes to avoiding adverse outcomes?
Grimm: Be prepared before you start. The hardest thing about anesthesia is that you don't have the luxury of time. If you're caught
off-guard, then you're trying to play catch-up. Veterinarians who are prepared or technicians who are well-trained are at
an advantage because they don't have to spend precious time trying to figure out what's going on and learning how to solve
the problem. They've developed the skills they need to deal with those emergencies.
Additionally, selecting cases to anesthetize that don't exceed the skill level of the people in your practice can minimize
catastrophic complications and poor anesthetic outcomes.
Our profession is very diverse, and care providers have a range of skill levels, environments they work in and constraints
they work under. One standard anesthetic or monitoring protocol doesn't fit all, and I think everybody has to remember that.
The adverse outcome that everybody worries about is death, which is an extreme and permanent catastrophic outcome. Most published
studies indicate that about 1 in 2,000 dogs and cats die during the anesthetic period. If you look only at sick patients,
it tends to increase to about 1 in 500. Interestingly, for healthy human patients it's unusual to have an anesthetic death.
There are many reasons dogs and cats are so much more prone to anesthetic mortality, but to improve mortality rates in the
veterinary profession we may want to approach an accidental death or complication in a manner similar to when a plane crashes.
In that case the NTSB (National Transportation Safety Board) tries to dissect the situation the best it can, recreate it,
figure out what went wrong and what can be done to prevent future incidents.
I think that's a good approach to take in our practices. Sometimes it makes a difference, sometimes it doesn't. But an honest
evaluation of what happened is usually beneficial.
Wetzel is a freelance writer in Cleveland, Ohio.