Trazodone ( 300 mg ) was administered orally , as two 150 mg tablets , in accordance with the stress plan [ 4 ] . After 1 hour , the trazodone did not appear to have had an effect on the patient ' s stress levels . The plan was reviewed and the VS prescribed a constant-rate infusion ( CRI ) of dexmedetomidine .
At the author ' s practice , owners complete a questionnaire before a patient ' s admission , to support the holistic care of the hospitalised patient . On admission of this patient , there had been no indication from the owners that the patient suffered from separation anxiety , and no sign of this during the consultation . Food was offered on recovery , as per the routine feeding sheet provided by his owners . The dog ate well but was so stressed that he vomited some of the food .
The level of stress experienced by the patient was discussed with the VS and consideration was given to whether the patient could go home and return for surgery . However , due to logistics and the distance of travel for the owners , this was not feasible . Therefore , a further stress management plan was sought from the VS , giving permission to put the patient on a CRI of dexmedetomidine . Following the practice ' s protocol for patients weighing more than 15 kg ( Appendix 2 , pages 46 and 47 ), a CRI was set up for this patient at a dilution rate of 25 μg / ml . An initial bolus of 1 μg was administered for swift effect and then the patient was given a 1 μg / kg CRI .
The patient ' s reactions were closely monitored ; he refused to lie down and continued to show signs of separation anxiety . As the patient may not have been used to being confined to a kennel , the company of a VN was provided . This encouraged him to lie down and relax . Once he had stopped panting , the VN withdrew slowly and quietly from the kennel , but it was not long before the patient recognised that he was alone and started barking again . The dexmedetomidine was increased to 1.5 μg / kg ( hospital protocol dose range 0.5 – 2.5 μg / kg / hour ( Appendix 2 , pages 46 and 47 )).
Patients on CRIs should be closely monitored to identify whether the administered dose is suitable , as all patients have varying tolerances . Ideally , this patient needed to relax so he could get adequate sleep overnight to reduce stress and aid recovery . By gradually increasing the dose and monitoring the effect , it was identified that 1.5 μg / kg was the adequate dose to achieve this for the patient .
During the night , the patient became unsettled again . His parameters were monitored , with temperature , pulse and respiratory rate within the normal ranges . He was given a 1 μg / kg bolus of dexmedetomidine and the CRI dose was increased to 2 μg / kg , which helped to keep him rested and settled for the rest of the night , ahead of surgery the following day . In cases such as this , eye lubrication would be considered , to reduce the risk of eye ulcers caused by increased sedation and reduced blink reflex .
Surgical premedication
The premedication for this patient before surgery was 0.3 mg / kg methadone and 3 μg / kg dexmedetomidine . He also had a co-induction dose of 0.5 mg / kg ketamine , due to his age and potential osteoarthritis pain . An induction dose of 0.75 mg / kg alfaxalone was prepared ( 2.59 ml ), but only 1.3 ml was required for adequate anaesthesia to allow intubation . It is worth noting that the ketamine co-induction would also reduce the amount of induction and inhalation anaesthetic agents required , which can have negative cardiovascular side effects in older patients [ 5 ] . This patient also had epidural anaesthesia consisting of 0.2 mg / kg morphine and 0.3 mg / kg bupivacaine to assist with intraoperative analgesia .
Post-surgery and recovery
The aim of minimising the patient ' s stress during recovery was discussed with the anaesthetist , and 5 μg / kg acepromazime was given intravenously before stopping the isoflurane anaesthetic agent . Acepromazine acts as a sedative , decreasing anxiety to support a stress-free recovery from anaesthesia . In line with the practice ' s inhouse postoperative / analgesia plan ( Appendix 3 , page 47 ), a sedation plan was also discussed with the VS , in case of an excitable recovery , before leaving theatre . In this case , the patient was already on a dexmedetomidine CRI , so this was to continue . This patient was also on a ketamine CRI for analgesia , which was reduced from 10 μg / kg intraoperatively to 5 μg / kg postoperatively . Eye lubrication every 4 hours would be required , due to ketamine causing dry eye and the additional dexmedetomidine sedation .
The patient was recovered in the recovery ward , which is located just outside the theatre to reduce the risk of hypothermia that can be seen in patients under anaesthetic that have to travel on a gurney to wards further away from the theatre . This recovery ward is also small , peaceful and away from potentially disruptive and / or vocal in-patients , which can be stressful for a patient waking from anaesthetic . The ward has a dedicated recovery nurse who is aware of each patient ' s plan . The patient ' s recovery went well ; he woke up calm in a peaceful environment with minimal traffic and few other patients . No further sedation was required , which seemed to assist the good recovery of this patient .
The patient was left to fully recover in the ward until he was ready to stand and walk unaided . The success of the recovery could be due to the dedicated ward being a calm , peaceful environment , with attention given to the recovering patient . In contrast , a normal ward could be loud , with lots of traffic , which could be stressful and confusing to a patient waking from anaesthetic .
Risks associated with anal sacculectomy surgery include straining to defaecate , faecal incontinence and surgical site infection , all of which can cause stress in any patient
42 Veterinary Nursing Journal