RE: Doubting myself

Laura Kidd — Tue, 28 Apr 2015 18:30:40 GMT

Hi, you have had some really useful answers thus far.

Remember under schedule 3 of VSA 1966, it should be the VS deciding whether iso/ gas flow etc. should be increased/decreased; albeit based on your observations. It should not be up to you to have to make this decision.

I would suggest you report your observations/clinical findings and ask do you want me to turn up, turn down, leave as is. Then you might feel less alone in having to make a judgement: there is more of a shared communication.

Experience is great and you will develop your confidence again.

RE: Doubting myself

Susanna Taylor — Tue, 28 Apr 2015 15:01:52 GMT

HI There,

Firstly, Well Done for seeking some help and advice with this. It can be much easier to ignore/accept things like this than it is to admit a problem and seek the answer, to hats off to you there!

Secondly, you are certainly not alone. There are many many people who face the same situation in anaesthesia as you:- you get 'trained', start doing GAs, everything is fine initially, but then you start seeing things that don't make sense and you're not prepared for.

One of the main reasons for this (in my opinion) is that anaesthesia training for vets and nurses is too short and often too rushed. This isn't your fault but a wider one of the profession.

I remember when I was starting out being so freaked out by anaesthetics that I vowed to avoid them for my whole career! It turned out I couldn't, so instead I started reading and learning privately (and you can see from my signature at the bottom where that has led me!)

Thirdly then, don't doubt your ability to monitor anaesthetics - the pure fact that you have picked up on this reoccurring problem shows you are monitoring very well. If anything, doubt the level of knowledge you have and strive to improve that! (but Im not blaming you for that, as per my second point!)

So, to look at your problem itself

Cardiovascular effects of Propofol wear off much quicker (under 10mins) so its not that. Potentially if you are using medetomidine (domitor) premeds it could be that wearing off - they don't have too profound effect on respiration either. Medetomidine top ups can be given to rectify the situation

Generally, and as you say every case is different, the main cause for increasing HR under anaesthetics is PAIN. The level of pain that causes inc HR in each patient will depend on a lot of factors- drugs, chronic pain, personal variences... so for some it could be the first incision, some not till intense tissue handling, some just being positioned in xray. So everytime you see a raise in HR, consider if something has happened that is causing a pain response. If you can link it to something its time to inform the vet and ask if you can do something to treat the pain,- That is not turn up the Iso as iso is not an analgesic (it just masks the signs of pain). I appreciate this may not be easy to do as a new nurse, and your vet may not agree or respond appropriately but it is still the duty of a nurse to report pain even if we can do no more than that. Regarding the HR not going down after the painful bit, once the body has been sensitised to intense surgical pain, it will not necessarily return to normal when the pain has stopped - this is called sensitisation.

HR also rises with a drop in blood pressure although anaesthetised animals can not do this as well as concious animals. If you are not routinely measuring BP its well worth starting and seeing if that links in. The answer to low BP is LESS Iso and potentially more fluids.

Of course, it is possible your patients are lightning at this point of anaesthesia, and HR often will rise before RR does in this situation (BP often before HR so another reason to monitor it!) BUT the question is WHY - if a patient has been stable on a particular % of ISO, they will not suddenly become light for no reason whilst receiving that same %. Either they are no longer actually receiving that % (equipment problems could cause a drop in %) or more likely, that % is no longer effective as they are responding to pain - back to the previous point!

So in summery, turning up the Iso at the point you are mentioning is almost never the answer. However, there are a lot of people out there who do this nevertheless with out thinking it through.

I hope this long reply has made some sense! If you have further questions, please feel free to ask on here, message me privately, or contact me through the AVA on ava.susanna@yahoo.co.uk - The AVA is here to help for things like this!

Also, as ever, interested to hear if anyone else has anything to add to this question!

Best regards

RE: Doubting myself

Mark Hedberg — Tue, 28 Apr 2015 14:31:26 GMT

Hi Anon!

Don't worry, we're here to help! Don't doubt yourself, if you were useless they wouldn't have hired you, promise!

http://bja.oxfordjournals.org/content/87/5/748.full

[quote]

Inhalation anaesthetics decrease heart rate in isolated hearts but mostly increase heart rate in the intact organism, although most inhibit sympathetic drive. [/quote]

If your practice has a BSAVA manual of anaesthesia and analgesia, it's well worth a read of chapter 7 - good outline of anaesthetic monitoring. If you can't ask colleagues about this, ask about going on anaesthetic CPD - quite a few places offer good information on up to date anaesthesia practice.

Good luck!

Cheers,
Mark