When I worked in GP practice, I loved anaesthesia. I was a GA nerd through and through. In fact, it was by (very happy!) accident that I ended up in medicine. I had always planned to do anaesthesia!

Fast forward a few years, and I had gone from doing anaesthetics every day to hardly doing them at all - being the only medicine nurse for 3 clinicians at the time, I was busy helping with admit appointments, processing samples, assisting with inpatients, performing nurse clinics, running scopes and assisting with procedures… leaving the monitoring of my patients to other VNs.

This led to a huge dip in my confidence when it came to anaesthesia. When working towards my VTS, I knew this was something I needed to improve - so I spent time with our anaesthetists, pushed my comfort zone, and eventually my anaesthesia confidence increased.

Lots of you have asked me to cover anaesthesia on this page over the years, so I’m excited to finally begin this new series all about anaesthesia for medical patients!

Medical patients can be complicated anaesthesia candidates, having multiple comorbidities increasing their anaesthetic risk. In the first post in our anaesthesia series, I’ll share my 4 top tips for safer medical anaesthesia. Over the coming few posts, we’ll look at specific anaesthesia considerations for different diseases and medical procedures, too!

Consider your patient’s disease

One of my favourite things about medicine is that every patient is an individual. They’re not a young healthy patient in for an elective procedure.
They’ve not had an injury requiring a ‘set’ procedure such as a cruciate repair, for example.

They’re in the clinic because they have some kind of illness or disease - and this will impact the anaesthetic choices we make for them.

Let’s look at a few examples

• Patient one: A 5-year-old DSH with CKD presenting for restaging bloods and sedation for abdominal ultrasound

• Patient two: A 3-year-old spaniel with suspected immune-mediated polyarthritis (IMPA) requiring x-rays and joint taps

• Patient three: A 9-year-old labrador with suspected protein-losing enteropathy (PLE) requiring a GA, abdominal ultrasound and gastrointestinal endoscopy

Each of these patients has a very different disease process affecting their ASA status, anaesthetic protocol choices and specific monitoring requirements.

For our renal patient, we want to monitor blood pressure closely and maintain renal perfusion - we would likely have a higher cutoff value for blood pressure intervention in these patients. Lower blood pressures will result in lower renal perfusion, and can contribute to acute kidney injury, for example.

Our IMPA patient is going to be in pain. They’re also having a procedure that requires them to be manipulated a lot - so analgesia is a big consideration. We also need to avoid any NSAIDs in these patients, since steroids will form the main part of their treatment. So what alternative analgesia choices do we have?

Our PLE patient will be hypoalbuminaemic, since these patients lose albumin through their diseased GI tract. This drops their colloidal oncotic pressure, resulting in things like pleural effusion (impacting ventilation) and reduced intravascular volume (impacting blood pressure and overall perfusion).

The take-home message

Our anaesthesia considerations will vary significantly for respiratory, endocrine, renal and urinary, hepatic, gastrointestinal, haematology and immune-mediated disease patients. So before you even get to preparing for your GA or sedation, think about how your patient’s disease affects them, and how this will impact their anaesthetic.

Consider your patient’s procedure

Much like their disease, the procedure we need to perform will also heavily influence our anaesthesia choices.

It dictates the difference between sedating and anaesthetising your patient, for example.

It also dictates the analgesia choices you and your veterinary surgeon make - because nurses, we should be involved in these decisions too, even if we can’t prescribe!

And it dictates our options for local or regional blocks - many of which we can perform as nurses under schedule 3. Learning to perform these is a fantastic skill for nurses to develop!

Let’s take our IMPA patient as an example. To diagnose and stage IMPA, we will usually perform:

• Chest x-rays

• Distal limb x-rays

• Abdominal ultrasound

• Joint taps

These theoretically are all procedures that could be performed under sedation. However, this procedure is likely to be long, and the patient will require quite a lot of manipulation throughout. We also know that IMPA is painful. If we were to sedate this patient, we’d likely need to give them several top-ups of sedation or induction agent. It may, therefore, be better to just anaesthetise them from the beginning.

Fail to prepare, prepare to fail

Planning and preparation are key to any successful anaesthetic. We know that anaesthesia and patient safety go hand-in-hand - so before we touch our patient with any drugs, we need to make sure the following preparation and safety bases are covered.

Pre-anaesthetic assessment

Before making an anaesthesia plan, we need to perform a thorough patient assessment. This is something that can - and should - absolutely be performed by nurses. It should include:

• Thoracic auscultation, respiratory examination and pulse palpation

• Collection of vital parameters (TPR, MM/CRT, BCS, weight)

• A temperament/demeanour and pain assessment

• Assessment of hydration and perfusion status

Once this has been performed, we can then begin to work with our vets to formulate an anaesthetic plan.

Equipment and machine checks

Before administering any medications to our patient, we need to ensure the equipment, area and team are ready for the planned procedures. This will involve:

• Preparing and checking the anaesthetic machine and breathing system

• Leak checking the ET tube cuffs (if general anaesthesia is performed)

• Ensuring monitoring equipment is available, on and working

• Ensuring syringe drivers and infusion pumps are on hand

• Ensuring the equipment required for the procedure (e.g. the endoscope) is set up, has been tested and is functional

We also need to ensure that drugs and emergency interventions are available nearby - such as the crash trolley and/or suction, for example. When you’re anaesthetising an especially high-risk patient, it’s also wise to pre-calculate your doses of common emergency drugs.

Checklists, checklists, checklists

Checklists might not seem like a necessary or fun task, but they are an established method of error reduction in practice. There is a lot of evidence surrounding their use in human medicine, with the WHO surgical safety checklist reducing complications and mortality by over 30%.

The use of anaesthesia checklists in veterinary medicine is becoming commonplace, with tools such as the AVA anaesthesia safety checklist and the AHT surgical safety checklist being used in more and more clinics.

However, it’s important that we use these tools for all patients and procedures, not just surgery - so think about how you can implement pre-procedure checklists for things like endoscopy, feeding tube placement and other minor procedures, too!

There is no such thing as over-communication

Communication is vital during any procedure - or really, at all times in veterinary practice in general! But it’s perhaps especially important in high-stress or intense work, during anaesthesia, and during things like CPR.

As the person monitoring the anaesthetic, you should be in charge of what happens during the procedure.

What do I mean by this? If you feel like the patient isn’t stable and you need the team to stop what they’re doing whilst you sort things, say. If you’re concerned about the patient in any way, say.

Procedures should be a collaboration between the person monitoring the patient and the team performing the procedure, not one working against the other - so don’t be afraid to communicate how the patient is doing, or if you have any concerns.

It’s easy for the procedure team to lose track of time when they’re trying to concentrate on a particular task. They may therefore not notice a complication or signs the patient is deteriorating. If you’re worried - speak up! And if the team is struggling to do something, it can be useful to set a time limit on that particular task, before abandoning or adjusting the plan. That way, the risk of complications or excessive delays to the procedure is minimised.

So there you have it - my 4 top considerations for safer medical anaesthesia. Consider both your patient’s disease process and the procedure to be performed, prepare everything in advance, and don’t be afraid to communicate any concerns! By having these 4 things at the front of your mind during your procedures, you’ll have safer anaesthetics with less fear!

Do you love anaesthesia or is it an area you’d like to increase your confidence in? DM me on Instagram and let me know!

References and Further Reading

1. AVA, 2014. Anaesthetic Safety Checklist Implementation Manual [Online] Alfaxan. Available from: http://www.alfaxan.co.uk/images/downloads/AVA-Checklist-Booklet-Digital.pdf

2. Love, L. 2019. Checklists in Veterinary Anaesthesia: Why, When and How [Online] AVAS. Available from: https://www.mynavas.org/post/checklists-in-veterinary-anesthesia-why-when-how

3. Ludders, JW and McMillan, M. 2016. Errors in Veterinary Anaesthesia. Iowa: Wiley-Blackwell.

4. World Health Organisation. Safe Surgery [Online] WHO. Available from: https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery