Managing the Surgical Patient's Journey Through the Hospital

Introduction

Surgery is frequently performed in small animal practice with operations ranging from routine elective sterilization procedures to complex urgent or emergency procedures. In order to manage the surgical patient in an optimal way, the clinical team will need to be in command of every aspect of the animal’s management. This process begins with an accurate diagnosis whenever this is possible and includes carefully considered conversation with the animal’s owner so as to gain informed consent for the intended procedure. In addition, sufficiently detailed communication with those involved with the in-hospital care needs of the animal must take place so that the nursing and surgical teams can deliver preoperative, intra-operative, and postoperative care that is both thorough and tailored to that animal’s needs. Finally, the home-care requirements and any follow-up appointments will need to be explained to the animal’s owner at the time of discharge, so that the ongoing recovery can be carefully managed and any complications identified quickly and addressed appropriately. From a medical perspective, an accurate diagnosis and selection of the appropriate surgical procedure are critical, as is the proficient performance of anesthesia and the surgical procedure as well as careful, postoperative care. The true foundation of a successful patient journey, however, is in the way communications surrounding the treatment happen, and the detail they contain.

Part 1: Prior to and Upon Admission

Owner Communication

Discussing the Procedure

Prior to admission of the animal, the veterinarian should make it clear to the owners, in lay terms, what procedure(s) are going to be performed on their pet, what the intended outcome should be, what potential unintended outcomes or complications may occur (ie, the hazards of such an intervention), and the time gap until the next communication about their pet’s progress.

Informed Consent

Ideally, all owners should then provide their informed consent to the procedure, in the form of a signed “consent” form that identifies the animal and owner, names the planned surgical procedure, contains an estimate of cost, and mentions the more common potential complications. Prior to admission, the animal should be fitted with a temporary identification collar.

Preoperative Patient Preparation

History Taking

The acquisition of a complete medical history from the pet owner is essential. For healthy animals undergoing elective surgery such as sterilization, this serves to ensure that the animal is suitably “ready”; so, vaccination history, worming history, and recent feeding history must be established at admission. For sick animals, this is the first step to learn what might be wrong and will inform subsequent investigations and diagnostic tests. Although this can be time consuming, careful attention to the historical features of disease can yield massive benefits in terms of definition and refinement of the “problem list” and organ system involvement.

Physical Examination

The surgeon should perform a complete physical examination of the patient prior to all nonemergent surgery. Aspects of the examination that should be emphasized include:

• Overall state of mentation and mobility

• Body condition score

• Mucous membrane color and capillary refill time 

• Oral examination

• Superficial palpation of the neck, thorax, abdomen, and limbs

• Arterial pulse rate and quality

• Peripheral lymph node palpation

• Abdominal palpation

• Auscultation of the thoracic cavity heart sounds, rhythm, and lung sounds

• Examination of external genitalia

• Rectal examination

Part 2: The Preoperative Period

Preparing the Team

Preoperative Preparation

The clinical team is ultimately responsible for preparing the patient for surgery. This preparation may be minimal for healthy animals undergoing elective surgery but may be more complicated for sick animals. It is essential that careful attention is given to the animal’s medical stability in order to optimize the chance of successful anesthetic and surgical outcome.  Such considerations include:

• Has food been withheld for an appropriate length of time?

• Is intravenous fluid therapy required prior to anesthesia?

• Are electrolyte and acid-base corrections necessary prior to anesthesia?

In order to ensure appropriate preparation of the patient, verbal and written communications must be provided for the patient care team so that everyone knows the patient signalment (breed, age, sex); what the animal has been admitted for; what it is having done and when; what preoperative blood tests or treatments, including fluid therapy, are required; and whether or not food or fluids can be made available for the animal to take orally. The written instructions on the “treatment sheet” should be signed by the responsible veterinarian and placed in a prominent location so that all those involved can easily refer to them.

Checklists

Checklists have become the standard of care in human medicine and have greatly reduced the incidence of intraoperative errors. Although these seem “mechanical” in approach, having pre-agreed checklists to ensure full attention is paid to presurgical, anesthetic, and surgical preparations has been shown to reduce errors and lead to a more efficient surgical team and less wasted time. These checklists are easy to produce and should take little time to complete but should form part of the regular routine as well as forming part of the patient record so that they can be referred back to, should the need arise.¹ For instance, simple protocols such as painting the nails of the limb to be operated with an elective orthopedic procedure at the time of admission may in fact prevent the wrong limb from being operated on.

Figure

Example of preoperative checklist

Preparing the Patient

Principles of Perioperative Antibiotic Use

The use of antibiotics in surgery has the potential to reduce the incidence of postoperative wound infection; however, antibiotics are not a substitute for aseptic surgical technique, gentle tissue handling, adequate hemostasis, and the judicious use of suture material. The use of prophylactic antibiotics must also be weighed against the potential adverse effects such as organ toxicity, hypersensitivity reactions, development of resistant infections, and the potential for emergence of resistant strains of bacteria in the environment.

The goal of prophylactic antibiotics is to have adequate levels of the drug in the wound and surrounding tissues at the time of surgery. To be effective, the antibiotic concentration in the tissues should be greater than the minimum inhibitory concentration (MIC) for the bacterial isolates that are most likely to contaminate the wound. The concentration of antibiotics in the tissues is determined by the specific absorption, delivery, and elimination phases for the drug.  To ensure rapid absorption, it is generally recommended to administer perioperative antibiotics intravenously (IV) to ensure maximum effectiveness. Antibiotic delivery to the tissues can be affected by protein-binding, lipid solubility, and other diffusion barriers such as the blood:prostate barrier.  Antibiotic elimination is usually through renal excretion and/or hepatic biotransformation.

Most common antibiotics will reach peak serum concentrations within 30 to 60 minutes after IV administration and should, therefore, be given at least 30 minutes prior to surgery.

Antibiotic concentrations in the wound fluid parallel the serum concentrations due to the increased capillary permeability at the wound site and the high surface area to volume ratio in the wound compartment. Repeat doses of antibiotics may be necessary to maintain effective wound concentrations depending upon the potential bacterial contaminates, the duration of surgery, and the elimination profile of the drug. There is no proven benefit to administering prophylactic antibiotics any longer than 24 hours after surgery.

Wound Classification and the Use of Antibiotics

Wounds are classified into four categories based on an estimate of the degree of contamination. The classification of the wound will determine if antibiotics are indicated and whether they will be used in a prophylactic or therapeutic manner. As a general rule, prophylactic antibiotics are not indicated for routine clean surgical procedures unless surgical implants (eg, total hip replacement) are being used or the consequences of infection would be devastating for the patient. Certain clean-contaminated procedures warrant prophylactic antibiotics if the contamination is from an area that has a high bacterial population and is likely to cause infection (eg, colonic surgery). Contaminated and dirty procedures warrant antibiotic treatment that may be considered either prophylactic or therapeutic depending upon the timing of the administration of the antibiotics.

Wound Categories

• Clean - relatively nontraumatic (ie, sharp trauma), not inflamed, no break in sterile technique, and where the respiratory, gastrointestinal, and/or urogenital tracts are not entered. 

• Clean-contaminated - gastrointestinal or respiratory tract entered without spillage, urogenital tract entered without infected urine, oropharynx entered, minor break in sterile technique. 

• Contaminated - gross spillage from gastrointestinal or respiratory tract, entering biliary or urogenital tract when infection is present, major break in sterile technique, fresh traumatic wound.

• Dirty - bacterial infection is encountered. Examples include traumatic wounds with devitalized tissue, foreign material, or the presence of pus.

Factors Influencing the Development of Wound Infection

• Type and length of surgical procedure - prolonged surgical procedures increase local tissue damage and disrupt local immune responses.  Each additional hour of anesthesia time over the first hour increases risk for infection by 30%.²

• Degree of wound contamination - Total bacterial burden will influence the development of surgical site infection.    

• The use of implants or foreign material - surgical implants or excess suture material left in the wound may trap bacteria or disrupt local immune responses.  

• Type of bacteria contaminating the wound - certain bacteria may have increased virulence or resistance, making treatment more difficult. 

• Host immune competence - immune suppression due to disease, chemotherapy, or malnutrition may increase the risk for wound infection.  

• Spectrum of activity and concentration of the antibiotics used - inappropriate choice of antimicrobial or dosing protocol may result in treatment failure.

Part 3: The Operative Period

Immediately Prior to Surgery

Ensure the Team Is Prepared

• Preoperative checklist (see Part 2: The Preoperative Period)

• Preparation of patient and personnel

• Prevention of surgical site infection (SSI)

• Duties, roles, and communications

• Controlling the controllable - organization and preparation, rather than speed, to minimize total anesthesia time. Preparation of anesthetic equipment and surgical instruments prior to the procedure, to promote efficiency.

Utilize "Time-Out"

Similar to checklists, it has been shown that taking time out to introduce the surgery team, the patient, the intended procedure, and the concerns about risks from a surgical and anesthetic perspective, prior to commencing surgery, reduces operating room mistakes.³ This should also form part of the surgical ritual.

The Surgical Period

Aseptic Technique

Veterinarians perform many different routine and complex surgical procedures on a daily basis.  Important factors for preventing postoperative infection include maintaining a clean hospital environment and practicing sterile techniques. A thorough understanding of the principles of aseptic surgery and proper techniques for equipment sterilization are necessary to reduce the incidence of postoperative infections.

Preparation of the Surgeon

Scrub suit - a comfortable, clean, lint-free, cotton/polyester blend that is easily cleaned. The scrub suit provides a partial barrier to micro-organisms and reduces the contamination of the surgical field. Laundering should take place within the practice at a temperature >70°C. Drying scrubs in an electric dryer is important, as it is this drying element that plays a significant role in reducing the bacterial burden.⁴  

Shoe covers - used for covering street shoes to prevent contamination of the operating room from outside bacteria.

Cap and mask - used to prevent droplets of saliva from entering the surgical site when talking.  Masks filter particulate matter of various sizes depending upon the type of weave and material of the mask.

Gowns - worn to provide a barrier between the surgeon and the patient.  Gowns can be either disposable or reusable and are usually made of high density cotton that is coated with a water repellent or made of synthetic materials. There are advantages and disadvantages for each type of gown including cost, barrier capability, cleaning requirements, and longevity that must be considered for each practice.

Hand Scrub vs Hand Rub - Traditional hand scrubs involve timed preparation of the surgeons’ hands, typically with povidone-iodine or chlorhexidine gluconate. Additionally, new hand rubs with alcohol-based agents have actually been shown to be more efficacious than surgical scrubs at reducing bacterial flora on the surgeon’s hands.⁵

Gloves - worn to reduce the transmission of micro-organisms from surgeon to patient and vice-versa. Usually made of latex or vinyl that is coated on the inside with talc (magnesium silicate) or corn starch to make donning easier. Puncture holes develop relatively easily so gloves should not be considered completely impervious and do not replace an effective hand preparation.

Preparation of the Patient

Hair removal - perform a wide clip using clippers immediately prior to surgery. Use a sharp blade and avoid accidental cuts or burns. Clipping hours or days before surgery increases the chance of wound infection by allowing bacteria to colonize the cuts in the skin. Razors are not recommended for hair removal because they are more likely to cut the skin and increase the chance for wound complications. Excess hair should be vacuumed away before preparing the skin.

Skin disinfection - the most common skin disinfectants are povidone-iodine antiseptic solution diluted in sterile saline (used for areas involving mucous membranes) or chlorhexidine gluconate (for intact skin). The surgical site is initially prepared outside the operating room with chlorhexidine gluconate diluted in water at a 50:50 ratio. The final surgical site preparation is performed in the operating room. This is done in back and forth motion, horizontally and vertically, over the incision site with a single use chlorhexidine scrub followed by sterile alcohol wipe. Alternatively, the scrub can be performed in a circular fashion starting from the incision site and working outwards toward the edge of the clipped area. A spray of alcohol and/or a disinfectant solution can be applied as the final step in surgical site preparation.

Draping - sterile disposable coated-paper or reusable cotton drapes can be used for isolating the surgical site. The drapes are usually placed in a four-corner pattern overlapping with each one. The drape on the side closest to the surgeon should be placed first and then the other drapes systematically placed, being careful not to contaminate them as they are positioned. Hands should be protected by wrapping them in the corners of the drape as they are placed on the patient. In order to prevent contamination, the drape should not be moved closer to the surgical site once it has been placed on the patient.

The Analgesia Protocol

The value of a well thought out analgesic protocol is incontrovertible in terms of animal welfare and overall speed of recovery from a surgical procedure. The modern analgesia provision is for pre-emptive administration of analgesia (prior to surgery) that often involves more than one analgesic formulation (eg, opioid, nonsteroidal anti-inflammatory drug [NSAID], and local anesthetic). Postoperative analgesia should be continued with parenteral administration of medication (typically opioids) in the hospital and should ideally be based on the results of an objective measure of animal discomfort or pain score (See Short Form of the Glasgow Composite Pain Scale). Finally, there should be provision of oral medication (typically oral NSAIDs) at the time of patient discharge.

Hypothermia can increase perioperative blood loss, increase anesthetic recovery time, increase risk of cardiac arrhythmias, slow drug metabolism, and increase wound infection.  It is important to use (safe) warming devices immediately after induction of anesthesia such as purpose-made warm air or warm water circulating blankets. Warning:  thermal injury can result from prolonged exposure to heating devices set at temperatures that are only moderately too high.

Immediately After Surgery

Before Closing

• Counting of the consumables should happen before any body cavity is closed:

  • Swabs/sponges (radio-opaque marked)

  • Needles

  • Instruments

  • Ideally, there should be one clinical waste bag per operating room, one per procedure.

• Clean surgical incisional site with sterile swabs and sterile saline.  Apply sterile dressing over wound and leave it on the site for 24 to 48 hours.

• Establish who will notify owner about the results of the procedure.

• Ensure a quiet recovery area is ready for the patient.

Part 4: The Postoperative Period & Patient Discharge

Following removal of the endotracheal tube, recovering animals should be placed in a quiet recovery area under direct observation and carefully monitored until fully conscious; this promotes a calm recovery while continuing to warm the patient.

Healthy animals undergoing elective surgery should not require postoperative fluid therapy but sick animals may need to continue fluid therapy after surgery. Body temperature should be monitored and warming blankets provided, if necessary. In addition, frequent monitoring of mucous membrane color, respiratory rate and effort, and pulse rate and quality should be done during this time. The intensity of postoperative care required varies for each patient and depends, again, on the age of the animal, nutritional and immune status, nature of the underlying disease, and the surgical procedure performed.

The presumption should be that the animal is experiencing pain and analgesia should be provided until the animal is conscious enough to undergo meaningful pain scoring (See Part 3: The Operative Period, under The Analgesia Protocol); after that time, analgesia provision should be guided by the pain scoring.

Patient Discharge

The key to successful recovery of a surgical patient is the early identification and management of any complications. It will be the responsibility of the surgeon to explain potential complications to the owners at the time of discharge so they know how to identify concerns and bring them to the attention of the veterinary team. To facilitate this, it is essential that the communication at discharge equips the owners with the information they need regarding ongoing monitoring of their pet’s general demeanor and monitoring of the surgical site for signs of complications (eg, increased pain, redness, swelling, wound discharge). In addition, the discharge instructions should provide information about the ongoing administration of analgesia and any other management requirements of the wound, or its dressings or bandages. It is particularly critical for an animal that is being discharged with a limb bandage that the owner knows when it needs to be changed and what signs to look for that might indicate early bandage-related complications. The discharge conversation does not need to be lengthy and can be facilitated by providing the client with a discharge instruction sheet to read prior to the face-to-face discharge conversation.

An example of a discharge sheet is below. It should contain the patient details, the final diagnosis (if appropriate), and what procedure was performed. Critically, from the owner’s perspective, it should explain whether and how much the animal can be exercised, what ongoing medication is needed and how it is given, whether food and water can be given normally, and when they are due back with the pet for follow-up examination/suture removal.

Figure

Example of a discharge sheet

Summary

Successful management of the surgical patient requires excellent communication, detailed preparation, and manual dexterity. Clients must be advised of what treatment is being planned and must give their informed consent. The most efficient way to remove doubt about patient treatment, and thereby reduce the risk for errors, is to introduce checklists and standard operating procedures that encourage all members of the care team to carefully examine what is being done and why. In addition, it is essential to develop a culture within the team, whereby if questions or concerns arise, anyone can voice these without fear of reprisal and that this should be done in the best interest of delivering optimal patient care. Preparation and efficiency, not rushing the surgical procedure, are the key to keeping total anesthesia time to a minimum. Finally, including the owners in the postoperative recuperation is facilitated by providing carefully thought out, concise discharge instructions that outline their responsibilities.