Even the most adept veterinary caregivers in anesthesia and pharmacology hold the anesthetic recovery period with the utmost reverence. Yet, we know it can be the time for the development of upper airway obstructions, post-surgical arrhythmias, malignant hyperthermia and other potentially life-threatening complications. Sometimes, these issues happen despite the team’s incredibly thorough planning and drug selection.
But while such crises stay top of mind postoperatively, we often fail to consider our patients’ emotional health during those critical times. Pain, stress, anxiety and fear play a substantial role in how patients recover inside and outside the hospital and can affect their immune health and wound healing.
Let’s consider three essential parts of the recovery period and how we can create the safest and smoothest journey home for patients.
1. The Emotional Response
Safer anesthesia, through lower doses of sedatives and anesthetic drugs, can reduce or eliminate a patient’s stress, anxious thoughts and fear. The result is helpful during routine surgical procedures and for patients who are critically ill, have comorbidities, or have compromised cardiovascular, respiratory or neurologic systems.
However, the reality in many veterinary hospitals is much different. A typical morning reveals the admission of emotionally stressed patients whose fear and anxiety increase as the day goes on, inadvertently creating a greater anesthetic risk.
The good news is that from time to time, many of our canine and feline patients are seen for a pre-anesthetic exam, bloodwork or a client discussion about an upcoming procedure. That’s an important time to discuss the pet owner’s expectations, address the travel experience and assess the patient’s body language in the hospital.
For patients demonstrating the need for emotional support, we can add a step to the pre-surgical instructions. Sending home anxiolytics for use the night before and the morning of admission can reduce fear, stress and anxiety, lowering anesthetic needs. Thankfully, we have many cost-effective drug choices with excellent safety profiles and few drug interactions.
Such drugs also may be given before discharge to support a calmer ride home and immediately afterward.
2. The Recovery Environment
We’ve all had patients who had what the medical record commonly calls a “rough recovery.” However, I challenge my colleagues to answer this: How many of your teams held a debrief to transparently investigate why the recovery was rough? Was it the anesthetic cocktail, the depth of anesthesia, a minimal pre-med, a quick transition of anesthetic planes, or all the above? We usually get myriad reasons, but we rarely consider how emotional stress factors into the equation.
Ask yourself:
- How does a patient with severe separation anxiety handle recovery in a small incubator?
- What behaviors will unmanaged pain create?
- Do we contemplate the triggers noted in the medical record, such as “Anxious around a specific gender,” “Sensitive to needles; needs topical lidocaine gel,” “Prefers standing blood draws” and “Is sensitive to certain smells”?
One way to improve anesthetic recoveries is by considering how a better environment can enhance a patient’s emotional health. For instance, specific sensory-related characteristics of recovery cages can help canine and feline patients feel more emotionally secure.
For example:
- The cage bottom should contain nonskid flooring and padding for senior pets and patients battling cachexia or chronic illnesses, orthopedic disease or mobility issues.
- For cats, hiding spaces are essential. Perches can add to their comfort by allowing the choice of vertical space.
- White-noise machines can drown out the dull hum of fluorescent lighting.
- Don’t place recovering patients in cages that face another one. That way, you’ll remove visual triggers.
- Change soiled towels to eliminate noxious or stimulating smells.
- When possible, apply compression garments impregnated with calming pheromones.
- Use warming blankets and fluid warmers to regulate the patient’s temperature.
3. Pain Assessment
Pain researchers understand that the amygdala is the permanent storage center for painful and fearful memories. Such memories, when triggered, often create more intense and escalated emotional responses as patients age. What does it mean for our postoperative patients and us?
For me, it means we have one core priority when managing a patient recovering from anesthesia: fluid pain assessment. Although our industry is battling staffing shortages, this is an instance when the hospital team must prioritize case management.
Every team member monitoring patients in anesthetic recovery should aim to assess pain from two perspectives: body language and physiologic parameters. Body language is telling, even to the point of the University of Montreal’s development of the Feline Grimace Scale.
Make sure your team members document changes in the anesthetic record. For example, does a dog move into a hunched position in recovery and vocalize when moved? Do a cat’s ears remain backward and the tail tucked? Are the pupils dilated for no pharmaceutical reason? And, speaking of the Feline Grimace Scale, what are the whiskers and muzzle doing?
All those changes are essential to note and report to the clinician in charge of the case. Then, pair the findings with the physiologic status. For example, a persistently elevated heart rate, an increased respiratory rate or effort, and elevated blood pressure can be linked to a patient in pain. When both body language and physiologic changes are present, we must intervene using pain management strategies appropriate for the individual patient. Without them, not only do we allow the patient to experience pain unnecessarily, but the painful experience becomes a permanent negative memory, later triggering stress and fear and worsening emotional health.
Advancements in understanding how canine and feline patients respond to pain and show stress, anxious tendencies and fear should stop us from focusing only on their physical health. Such an approach extends to other parts of the hospital where permanent negative emotional responses can form.
Careful preparation before a patient’s admission, conscious planning of the recovery environment and continuous monitoring for signs of pain will support all aspects of the patient’s health.
DID YOU KNOW?
According to the University of Montreal, the Feline Grimace Scale was developed using videos of “painful and nonpainful cats, mostly of client-owned cats presented to the Veterinary Teaching Hospital.” Details are at felinegrimacescale.com.