REHAB | Postoperative Care 1. Extubation The proper time to extubate is often based on a widespread misconception, sometimes called the “two swallows rule,” or the “3 swallows rule,” or the “5 swallows rule.” This is a very unfortunate urban legend, that can lead patients to serious trouble. Two, three or even ten swallows may not mean that patients are alert enough to continue swallowing and breathing efficiently on their own. The more appropriate time to extubate is when a patient is alert, preferably has lifted their head up at least once, and begins to chew. The next challenge is to pull the endotracheal tube before the patient chews it in half! This is especially true with brachycephalic dogs. They can notoriously seem wide awake, yet they sometimes tolerate an endotracheal tube for an hour. Some patients have an increased risk of aspiration (or suffocation) if the tube is pulled too early. Each patient recovering from anesthesia and/or surgery should be under the direct supervision of a technician until extubation – and beyond. We still need to remain alert afterwards: extubation doesn’t mean that recovery is over. It is just one step of the process. 2. Pain Management Pain management is the cornerstone of post- op care. Ideally, your nurses would pain score patients upon admission to the practice, and throughout their stay, including after surgery. This is the best way to be more objective about patients’ individual needs. We say that “every patient is different,” yet we tend to offer the same analgesia to all of them. Some colleagues are under the impression that CRIs are difficult, expensive or complicated to use. It’s quite the opposite: they are rather easy, affordable and simple to implement in a practice. In addition, you don’t need a fancy specialty hospital to offer CRIs. Many family practices use them on a daily basis very successfully. Rather than sticking blindly to a cookbook recipe (every 4 hours, every 6 hours, every 8 hours), pain medications should be given based on the patient’s needs. A patient’s pain level should be assessed periodically and treated as needed. Most practices have embraced the importance of preemptive pain management. It should continue beyond the OR. There are countless modalities we can choose from, depending on the patient and the procedure, including opioids, Constant Rate Infusion (CRIs) and anti-inflammatory drugs. Pain management should be a practice-wide awareness, rather than an afterthought (or worse: a choice made by the client). Your nurses should be empowered to play an active role in pain management. After all, the veterinary oath includes “the prevention and relief of animal suffering.” www.kruuse.com
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