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Systems for Recovery From Anesthesia

By Douglas J. Herthel, DVM

Horse Recovery Pool

A variety of systems are in current use to assist the recovery of an equine patient from general anesthesia. The safety of the anesthetized horse and of the personnel involved is the prime concern when a recovery protocol is selected. Smooth, controlled recoveries are especially desirable following orthopedic procedures. Since protection of the surgical repair is essential. A successful recovery is also more difficult after orthopedic procedures because of the pain associated with bone repair. Especially in cases of upper long-bone fractures in which analgesia cannot be obtained by perineural anesthesia.

The recovery protocols described herein are used at the Alamo Pintado Equine Medical Center. Two types of recovery systems are commonly used; a recovery room with ropes for assisted recovery, and a warm water pool recovery. The two systems allow for flexibility and backup for the difficult recovery case.
Many factors are involved in selecting the type of recovery system. The fracture type and extent, the temperament of the horse, and location & size of the cast required, and the type & duration of anesthesia all must be analyzed. Throughout a procedure, any of these factors can change and affect the type of recovery system implemented. Additionally, a horse having difficulty in a recovery room can be immobilized and transferred to a heated recovery pool via a sling or in soft hobbles. The same move can be made in reverse, although need for this is very unlikely.
The anesthetic regiment used at this clinic includes a combination of some or most of the following: xylazine hydrochloridea, detomidine hydrochlorideb, butorphanol tartratec, diazepamd, ketaminee, isofluranef, halothaneg, and atracuriumh. Combinations of these drugs have worked well for the anesthesia and recovery of orthopedic patients.

Recovery Room

The recovery room should be in close proximity to, but separate from the surgery suite. The recovery room can be the same room as the induction room if the surgical caseload is light. The recovery room should have padded walls and an easily cleaned, nonskid floor. A 12 inch-thick, moveable, vinyl-covered mat (5ft by 10ft) is placed under the animal during recovery. The best position for recovery is injured leg up, with the legs halfway off the mat and toward the wall. The recovery room should also have recessed wall rings for ropes. Head and tail ropes allow two people to assist a horse in rising. They allow the attendants to control the movement of the horse and to aid in supporting the horse while allowing it to lean against the wall for balance. The two attendants can maintain a safe distance from the recovering horse at the same time to prevent the horse from struggling and injuring itself. An escape route behind the two assistants is mandatory. This is system keeps the horse from using no more than a third of the recovery room and prevents the recovering horse from blocking the escape route for the attendants. Sometimes it is helpful to lean against the chest of the horse immediately after it regains it’s feet, to stabilize the horse by providing contact with the padded wall on the opposite side.

The 12-inch-thick, vinyl-covered foam mattress allows the recumbent patient to remain comfortable while exhaling the residual gaseous anesthetics. Postanesthetic sedation with xylazine, butorphanol, or detomidine allows the horse to exhale anesthetic gases before attempting to stand. This extends the recumbency time in recovery but prevents premature efforts to stand and increases the likelihood of a safe and smooth recovery from anesthesia. The presence of the anesthetist and an assistant in the recovery in the recovery room, monitoring the patient and assisting recovery with the use of head and tail ropes, is essential to prevent accidents. All room recoveries should be rope-assisted.

The recovery room should be quiet and darkened to reduce environmental stimulation to the horse. The room should be equipped with a suction line, an oxygen insufflation tube, an oxygen demand valve, and a case of emergency drugs and syringes. Close monitoring during the recovery phase is as imperative as intraoperative monitoring and includes vital signs, mucous membrane color, blood gases, chest excursion, eye signs, and pulse oximetry.

Floor surface is a critical factor in safe recoveries. The surface should be nonslip, even when wet. A slightly cushioned surface with a nonslip covering is ideal, for example, a removable floor pad consisting of a ½ inch thick, high-impact rubber material covered with an outdoor commercial carpet. A moveable pad (10 ft by 4 ft) works well, allowing thorough cleaning of the recovery room floor and mat. This system for room recovery is safe and atraumatic to patients and can be modified when necessary. The padded recovery room offers minimal risk of further injury to horses recovering from anesthesia following repair of small-bone fractures or application of a cast to lower limb fractures, and horses having undergone arthroscopic procedures.

Pool Recovery

The additional option of pool recovery is invaluable and often lifesaving in cases of difficult recoveries from prolonged and complicated procedures. Immersion of the horse in water after long-bone fracture surgery is usually the best way of protecting the integrity of the repair during recovery from anesthesia. It is also reassuring to have the pool recovery option in instances of certain anesthetic complications or other circumstances.

The pool should be designed to easily clean, safe to work around, economical to operate, and effective in helping horses with fractures to recover from anesthesia. It should also be designed to accommodate the loading and unloading of horses that have problems resulting in prolonged periods of recumbency. An additional function is the rehabilitation of horses with orthopedic conditions or laminitis by allowing these horses to swim.

Ideally, the pool should be built from poured concrete, plaster, and tile and should be filtered and heated with conventional pool equipment. Satisfactory dimensions are 12-ft long, 4-ft wide, and 8 ft deep. A hydraulically driven scissor-lift elevates and lowers the floor from 7 ½ ft deep to ground level. The hydraulic pump also operates a Jet Ski propeller recessed in the front of the tank. This serves to propel up to 1500 gallons of water per minute against a horse that is swimming for exercise and physical therapy. The pool also has strong Jacuzzi jets that are used for physical therapy.

The pool level can be quickly adjusted by adding water or pumping water out. The temperature can be adjusted from cool to very warm but usually remains at 90? to 95? F (32.2? to 35? C). On occasion, all the water is drained from the poor, leaving the recovered horse standing in the empty pool. Straw bedding can be placed on the lift floor to covert the pool to a narrow tie stall. Usually the sling used to transport the anesthetized horse to the pool is left on the horse while it remains in the empty pool. The metal grate floor allows water to flow through it without surging, as the floor is quickly elevated and lowered during the various stages of the horse’s recovery. The pool decking is covered with nonskid rubber matting to allow traction for the horse when it leaves the pool. The pool should be built directly beneath a rail system that carries a crane lift and trolley, which services the induction room, surgery suite, and recovery room. This location allows transport of the anesthetized horses from surgery or recovery to the pool, either in a sling or upside down in soft hobbles.

Pool Recovery Procedures

Special intraoperative and postoperative procedures are necessary if a surgical patient is to undergo recovery in a pool. The most important is waterproofing the surgical wounds. Additionally, bandages or casts must be water-resistant and durable in water.

Wound closure requires extra effort to provide a multi-layered, tight closure. An inverted, subcuticular, transdermal, continuous suture pattern is used in place of interrupted skin sutures, and wound drains are avoided. The wound is then sprayed with a cyanoacrylate wound cementi. This spray and a tight closure effectively waterproof wounds for as long as 4 days under water. If bandaging is required, only a non-adhesive dressing and gauze roll are used, with Elastikon placed over the bandaging. These wraps are changed shortly after the horse exits the pool. If casting is required, a water-repellent cast paddingj is used. This padding is applied easily and allows the skin to dry quickly after the horse leaves the pool. Horses with Gore-Tex cast padding, a fiberglass cast have been placed in the pool to swim every second day for 30 days and have surgical wounds, and skin that are still in excellent condition at cast removal.

At the completion of surgery, the horse is disconnected from the anesthetic machine and elevated from the surgery table with a sling and hoist. The arterial catheter and jugular catheter are anchored and glued in place. The endotracheal tube is also anchored so that intermittent positive pressure ventilation can continue with use of a Hudson demand valve. The horse is monitored and ventilated as it is transported to the recovery pool. Prior to lowering the horse into the pool, the floor is depressed to 7-½ ft, and two inflated car inner tubes are placed around the animal’s neck. A long rope is tied to the tail and run to a pulley on the monorail. Two ropes are tied to the halter, and the horse is lowered into the pool the remainder of the distance. The end of the endotracheal tube must be kept out of the water. The horse remains on the oxygen demand valve, an arterial line is available for monitoring blood gases, and drugs & fluids can be administered through the intravenous catheter. The sling remains in place but does not support weight; the horse is essentially floating. As the horse starts to recover, it is generally quiet in this environment. Some sedation is useful; especially prior to removal of the sling and before the floor is fully elevated to ground level. When the horse is adequately stable in the water, the floor is elevated to ground level and the horse is allowed to walk off the pool floor. In some cases of major long-bone fractures, the sling is left on for safety and support. The use of sedation, warm water, the tail rope, two head ropes, the sling, and the adjustable floor gives the equine anesthetist a safe method of assisting in the recovery of seriously injured horses.

The temperature-controlled pool with its Jacuzzi jets is an ideal environment for therapeutic treatment of postsurgical or idiopathic myositis, neuropathy, and weak patients recovering from surgery, and for water exercise therapy for orthopedic patients. The warm water and Jacuzzi jets massage and relax painful muscle conditions. The exercise provided by the patient’s swimming against the jets is nonconcussive and more therapeutic for orthopedic cases than rehabilitation using water treadmills. Such swimming allows for muscular rehabilitation with minimal skeletal stress. The same therapy can be used for horses with severe laminitis that have difficulty in walking but would benefit from the warm water, massage, and mild exercise.

Horses that are weak and remain recumbent can be kept in the pool for hours, days, or even up to a week to prevent cachexia and pressure sores and to expedite recovery. Patients quickly become accustomed to the routine and require a minimal number of staff members to complete the therapy. In most cases, the patients enjoy the pain-free time they spend in the pool.

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