PATIENT AFTERCARE AND

REHAB
JULIAN LUNN BVSc MVCS MACVSc
JLUNN@ARECVET.COM.AU
GOALS

• Immediate Post-Op

• Ongoing Hospitalisation
GOALS

• Immediate Post-Op
• Breathing
• Temperature
• Pain control
• Ongoing Hospitalisation
• Mobility
• Pain control
• Toileting
• Eating and Drinking
• Tubes

• Specific Situations
BREATHING

• Brachiocephalics vs others
• Post op obstructions – especially post upper respiratory surgery
• Rapid wake up
• Extubation; cats vs dogs
• Protect the airways as long as possible (Regurgitation)
• Head positioning
• Oxygen supplementation
• Flow by
• Nasal oxygen catheters
• Keep tubes, laryngoscope and anaesthetic on hand.
TEMPERATURE

• Patients will always be hypothermic

• Goal Temperature 37.5+°
• Active warming
• Bair Hugger
• Warm Fluid lines
• Blankets – “Shared Bodily Warmth”
• Beware of thermal burns (Temperature + Time)
• Hot-water bottles, heat mats, cautery plate
• Clipped areas
TEMPERATURE
 PAIN

Humans are described as having three facets of pain perception

based in response;
• Sensory-Discriminative: onset, location, intensity and character of
pain.
• These perceptions are due to interactions with the somesthetic cortex
• Motivational-Effective: autonomic, behavioural and emotional
responses due to projections into the limbic system and hypothalamus.
• Cognitive-Evaluative: cultural, experiential and attentive responses
that are due to cortical interactions.
PAIN CONTROL
PAIN "HURTS" AND CAUSES "SUFFERING", IN OTHER WORDS PAIN
ELICITS AN EMOTIONAL RESPONSE
• Opioids
• Bolus vs C.R.I.
• Oral
• Non-steroidal Anti-inflammatories
• Paracetamol
• Neuroleptics (Sedatives)
• Tramadol (Transdermal)
• Amantadine
• Benzodiazepines
PAIN SCORING

• Increases in
• Respiratory rate
• Heart rate
• Temperature
• Blood pressure

• Posture/attitude/Responsiveness
• Vocalising
• Aggression
• Eating, sleeping, etc.
• Direct palpation of the wound site
OPIOIDS

• Receptors
• Mu, kappa, delta, nociceptin
• Agonists
• Partial Agonists/Antagonists
• Administration
• Injectable
• Oral (Species Differences)
• CRI
• Epidural
• Local or slow release
NON-STEROIDALS

• Route of administration
• When not to use them
• Impact on the patient
• Healing
• Pain relief
OTHER ANALGESICS

• Local anaesthetic (local infusion, IV and topical)

• Ice packing
• Medications
• Tramadol (IV and oral), Amantadine, gabapentin
• Benzodiazepines
• Paracetamol

• Twilight anaesthetics – painful manipulations

MULTIMODAL ANALGESIA
ONGOING HOSPITALISATION
ONGOING HOSPITALISATION

• Mobility
• Pain management
• Toileting
• Feeding
EARLY MOBILISATION

• Improves cardiovascular and GIT function

• Improves blood supply to region
• Maintains muscle tone and joint function
• Part of the rehab
• Improves patient environment
EARLY MOBILISATION

• Use slings, towels, harnesses, etc

• Avoid slippery floors
• Get them out into the sun/moon light
• Protect the bandage
THE RECUMBENT PATIENT

• Prevent pressure sores/muscle trauma

• Plenty of padded bedding with good drainage
• Turn regularly
• This may require periodic sedation

• Consider urinary and rectal catheters

• Prevents urine and faecal scalding
• Improved comfort for the patient
FEEDING POST OP

• Generally as soon as possible

• Exception?
• GIT surgery?
• Portosystemic Shunts/Chronic liver disease
• Neurological disease
• Upper Airway Disease

• Cats vs dogs
• Feeding tubes
FEEDING POST OP

• What to feed?
• Protein – body protects fat
• Complicated starvation; protein stores mobilised
• Protein sources
• Type of food; hard vs soft, chunks vs liquids
• What stimulates the swallowing reflex best
• Which food type is more likely to contaminate or damage oral wounds
• Presentation is important
• Should you offer then take away
• What container suits cats best
HOW MUCH

• Resting energy requirement (RER) vs Metabolic Energy Requirement (MER)

• Feeding for MER (illness factor) increases complications
• Slowly increase caloric intake over three days to RER

• Cats:
• High protein requirement
• High level of gluconeogenesis all the time
• Refeeding Syndrome (too many carbs)
FEEDING POST OP

• GDV high risk patients

• Small frequent meals
• Elevated
• Reduce stress
• Monitor

• Oesophageal Dysfunction
• Check gag
• Elevate feeding
TOILETING

• Urine output must be established

• Get them up and out – Give them time
• Urinary catheters?
• Always have clean litter available
• Prevent urine scalding

• Constipation rare
• Don’t forget the purse-string
TUBES

• Indwelling Urinary Catheters

• Chest Drains
• Closed Suction Drains
• IV Catheters
• Wounds Soaker Catheters
• Feeding Tubes
TUBE COMPLICATIONS

• Infection
• Ingress; pneumothorax, pneumoperitoneum

Self Trauma
Ongoing Maintenance
URINARY CATHETERS

• Should be a closed collection system

• Preplacement preparations
• Sterile Technique
• Clipping?
• Flushing prepuce/vulva (iodine vs Chlorhexadine)
• Maintenance
• Flushing the catheter (or rather not flushing)
CHEST DRAINS

• Complication rate rises exponentially with time

• Longer there in the more likely something will go wrong
• At least three points of closure:
• G-clamp, three-way tap, cap
• Use a system when you drain (cap, tap, clamp…clamp, tap, cap)
• Must prevent self trauma
• Patient must always be in sight
PULMONARY DISEASE

• Aspiration Pneumonia
• Nebulisation
• Coupage
SURGICAL WOUNDS

• Checked daily
• Note swelling
• Colour
• Discharge
• Swelling is expected to some degree
• Dressings should be removed within 24 hours of the surgery for standard
wounds.
• Urine and faeces will increase infection rates
SPINAL PATIENTS

• Use it or loose it
• Any stimulations of the nerves stimulates the spinal cord
• Stimulation of the cord:
• Improves blood supply
• Speed nerve healing (remyelination)
• Retraining/Recruitment of nerves
• Careful with stability of the spine
SPINAL PATIENTS

• Physiotherapy in walking vs not walking

• Not walking
• Massage
• Passive Range of Motion
• Stimulation; tickling feet, hot and cold packs, touch
• Turing regularly with padded bedding to prevent pressure sores
• Walking
• Supported walking especially on slipper surfaces
SPINAL PATIENTS

• Urinary Bladder Management

• Urination a complicated event
• Not just about starting urination, emptying more important
• Detrusor atony
• A wet bed is not enough (Overflow incontinence)
• Expressing the bladder
• Diazepam
• Prazosin
FRACTURES AND CRUCIATE OSTEOTOMIES

• Early Mobilisation the main benefit

• Need to be careful in the first few days
• Support on slippery surfaces
• Pain relief
• Vasoconstriction
• Inappetence
• recumbency