Postoperative nursing
In the postoperative period, the VN has a vital role in the successful recovery of the brachycephalic patient. While the volatile anaesthetic agent is slowly lowered, the patient ' s airway should be checked for signs of regurgitation; if noticeably present, it should be suctioned away before extubation is performed.
The patient should be recovered in sternal recumbency, with the head slightly elevated and supported by a rolledup towel to allow effective breathing [ 15 ]. An emergency intubation tray should be kept beside the patient at all times in case of respiratory distress; it should contain ET tubes of a range of sizes, comprising the originally placed size and a few sizes smaller, a tracheostomy tube and a laryngoscope [ 14 ]. The patient should remain near an O 2 source in the recovery period to allow flow-by O 2 provision or intubation on O 2 if required.
Extubation should be done only once the patient is fully aware and recovered; intubation is usually well tolerated during recovery [ 2 ]. The ET tube cuff can be kept partially inflated to prevent any regurgitated material falling into the airway on tube removal [ 15 ]. The respiration pattern of the patient should be closely monitored at this time to help manage their condition and prevent respiratory distress from occurring in the event of a blocked airway [ 15 ].
The patient ' s temperature and SpO 2 should be continuously monitored at this point to prevent a difficult recovery and decompensation. A temperature less than 36 ° C will cause the patient to shiver, leading to a 400 % increase in the requirement for O 2 and energy, and so the patient should be warmed to 37 ° C to prevent this [ 16 ]. However, as mentioned earlier, active warming should be stopped when the body temperature reaches 37 ° C to prevent the patient from overheating and panting, which will irritate the airway [ 3 ].
SpO 2 can be easily monitored by attaching a portable pulse oximeter to the patient ' s tongue, lip fold, ear or prepuce, and this is generally well tolerated in these patients. Ideally, when the patient is breathing room air, the SpO 2 should be > 95 % [ 6 ], but as these patients have difficulty with O 2 intake, anything over 93 % is acceptable [ 15 ]. If the SpO 2 begins to dip under this value, supplemental O 2 or reintubation will be required.
The patient will require constant monitoring for at least 1 – 3 hours postoperatively [ 15 ] and ideally should be hospitalised for the first 24 – 48 hours in case respiratory distress occurs [ 17 ]. As soft tissue swelling can persist for a few days postoperatively [ 15 ], there is the potential for airway obstruction to occur, resulting in a tracheotomy being required. For these patients, the VN should make regular checks of respiratory effort, noise and rate, and report any changes to the VS. Placing the patient in sternal recumbency and supporting their head will assist the patient to breathe fully during recovery.
If the patient becomes stressed, postoperative sedation using low doses, such as a constant-rate infusion of medetomidine( 10 mg / ml, dose 2 – 4 µ g / kg / hour), can assist in keeping them calm [ 6 ]. Any changes in breathing noises should be reported to the VS immediately, and the VS may prescribe an injection of dexmethasone sodium phosphate( Colvasone 2 mg / ml, Norbrook, 0.22 mg / kg IV) to reduce the swelling in the airways [ 3 ]. Eye lubricant should also be continued in the postoperative period to prevent eye ulcers, as the opioids used before and during surgery will reduce tear production [ 18 ]; in addition, ketamine, which can cause dry eye, may be administered in some cases.
Based on the author ' s experience, some VSs may also request nebulised adrenaline every 4 hours( 1 ml adrenaline mixed with 4 ml saline) to help reduce airway secretions. This should be administered in a calm, reassuring manner and is generally well tolerated by patients. Eye lubricant should be applied after nebulisation, as the steam may cause ocular dryness. If the patient becomes unsettled, some distance should be allowed from the nebuliser, as the noise of the nebuliser can be distressing.
Feeding can resume within 8 hours of surgery. Meals should initially consist of wet food rolled into‘ meatballs’ [ 19 ]. This will help prevent small particles of food being inhaled and also reduces the chances of excessive air swallowing, which could lead to gagging and further irritation of the airway. The patient should also be hand fed initially to prevent gorging, which may lead to a blockage in the airway. Later meals may be fed in a bowl placed at a height [ 17 ], and the patient ' s daily food should be divided into 4 – 6 small meals a day for the first few days.
Discharge
The owner must be made aware that the patient should transition to using a harness exclusively for walks, ideally before surgery but most certainly in recovery and beyond [ 14 ], to help reduce pressure on the neck.
Medications should be clearly explained to the owner. A non-steroidal anti-inflammatory drug may be prescribed due to its analgesic and anti-inflammatory properties. Owners should be clearly informed about the appropriate timing of medication doses if corticosteroids have been used during recovery [ 6 ], as administering additional drugs too close together may increase the risk of gastrointestinal upset, regurgitation and subsequent aspiration pneumonia. Gastroprotectants may be prescribed to help prevent regurgitation.
Owners should also be informed of the importance of preventing airway irritation during the recovery period by avoiding the use of aerosols and scented candles or oils in the house and avoiding dusty environments.
48 Veterinary Nursing Journal