No one died… Anaesthesia into the future

Anaesthesia monitoring into the future

When I first started learning about anaesthesia I was worried about if the patient would wake up or even survive the surgery. I was thinking about this today and realised that my thinking about anaesthesia has evolved since then. It used to be that I was grateful no one died when I was doing anaesthesia as that would be bad, I would have failed, and it would have taken a life because of my failure.

Today however I realised that it is not just enough that my patient survives any longer; it is how they survive that is more important. It is the quality of the anaesthesia, the maintenance of the depth of anaesthesia and the quality of the recovery from anaesthesia. All of these can be managed with an understanding of physiology, the effects of drugs, and with the correct monitoring. There are specialists in anaesthesia and whilst previously they mainly resided within universities there are many that are moving to private practices and referral hospitals. This means that the quality of anaesthesia is increasing – and in some places is done by specialists that only do anaesthesia which allows a higher standard to be provided.

Something that has always been a big problem here in Slovakia is maintaining temperature as the heating in the hospital is not great, the weather regularly drops below freezing in winter and we do not have warming blankets or systems apart from microwave heat pads which tend to go cold on a long surgery. In addition our monitor does not include an esophageal thermometer so we do not have any continuous monitoring of the body temperature once the patient is under drapes.

Once surgery finished instead of the recovery being as fast as it should the decreased body temperature and hypothermia increased the time that patients took to wake up. This was not so great for the patient however in terms for learning it was something that increased my experience and understanding of the physiology of the body system. It gave me experience in how quickly the temperature of an animal can change and the importance of body surface to volume ratio. Hopefully in the new surgical hospital now it will hopefully be less of a problem with new heating systems.

This is not the only factor that is important when it comes to anaesthesia, one of the things that I find important and I do not like to be without is a cannula which is an injection port into a vein. Normally I would also include fluids here at a low maintenance rate so that if I get problems I can then increase the fluid within the vascular system quickly in response.

It seems that things always come in bunches and so last week we had a few patients that had unwanted heart rhythms during their surgeries. Emergencies can and do occur and in this case from seeing the rhythm on the monitor it took just a minute to prepare the medications needed and get them into the patients because there was an IV cannula in place giving us access.

Thinking forwards I see anaesthesia becoming more about the big picture of pain management to ensure a smoother anaesthesia and recovery without the patient experiencing pain. And that is the entire point of anaesthesia – to allow operations without pain.

Is length the most important thing? (Day -160)

Quality vs Quantity of life in dogs

I’ve recently spent some time within some of the top oncology (cancer) referral vets within the UK and been in consults with people who have to be told that the biopsy says it is cancer. One of the most difficult questions that pet guardians will then ask is how long a loved pet has left – this is an awful question that has to be answered so carefully because we just do not know.

We try to use evidence based studies looking at different treatments when discussing the options – however these studies over use statistics to give averages. Unfortunately within veterinary research many studies only have a small amount of patients which is caused by the way the veterinary industry works. This means that when looking at a study with average life duration from start of treatment of 3 months that some dogs may have died at 1 week whilst others lived until 9 months or a year. I am personally starting to believe that statistics should be limited to use only in sample sizes over a defined minimum limit to improve reliability (I wrote about statistics here).

However what is missing from most of these studies is perhaps even more important and is the second question that most pet guardians ask. That is what the quality of life is like. It is something that may sound strange however it is much easier to quantify quantity of life (i.e. days) than it is quality (i.e. happiness) of a pet.

This is still something in it’s infancy within veterinary medicine – with humans we can explain that it will hurt now but it will mean that they are good later. The first time I saw this discussed was within surgery decision making in the AWSELVA journal in 2014 (J. Yeates & S. Corr) to evaluate treatment options based on the amount of painful time vs the amount of pain free time.

This is something that is difficult though as we need to define how we recognise the quality of life. For example if we consider movement as an indicator as recently there have been studies using accelerometers (step counters) to monitor the activity of an animal. A study just published used this to measure the physical activity in dogs receiving chemotherapy as an oncology treatment which may be acceptable.

However if we look at dogs with neurological problems that may have abnormal circling or pedalling movements then activity may not be the best quality of life. Here is where other techniques may come into play with things such as a seizure diary being kept to record frequency and duration of seizures to allow comparison of good time vs bad time.

Hopefully soon we will have better measures for the quality of life – and be able to apply these when making decisions that may impact animal welfare.

Whats in a name? (Day -235)

Dog name tags on collar

One of my favourite books growing up was The Wizard of Earthsea. This book is the story of a wizard that has great power – yet this power is dependent upon knowing the name of something. Without this it doesn’t matter how great the power you have, you are powerless.

When you are doing surgery some doctors believe it is useful to dissociate yourself from the patient as that way you can do what you need to do without emotion. Personally however I believe it should be all about the patient. A name takes it from being just a dog or cat to a patient, someone that should be looked after and cared for to the best of my ability.

The first question that I will ask a pet guardian is the patient’s name. Something I have come to realise in doing this is that is not only does it give me someone to look after, when asking such a simple question in what are often traumatic times can help create calm. It’s such a normal thing to ask.

And in veterinary medicine calm is good – animals are so good at picking up on human emotion that if we are upset or stressed then they are upset and stressed. So asking for a name is a step down the stress ladder.

The pet guardian realise then that it is not just another animal to you, they realise you care, and they feel they are in the right place.

Dog in red collar with name tags

Being in Slovakia gives me another view on how medicine works. It’s amazing the time’s I’ve walked in and asked what is their name to find out that no one knows.  In the UK it is something I’ve never come across – we are good at getting the paperwork right – and we are expected to know the pets name.

Then again it can also cause problems when you rely on the computer and the records are out of date. I’ve heard stories where a pet has passed on across the rainbow bridge, and the guardians are in with a new pet who you naturally assume to be the pet that has passed. That is never a good situation however one that is easily fixed.

A name attaches the responsibility to you. When something goes bad you are sad because of the name. When something goes right you are happy because of the name.

Now my memory is absolutely awful for people, however I remember every single patient I have every treated.