Veterinary dental nursing procedures SAFETY, ANESTHESIA, POSITIONING

Usual GA precautions Appropriate monitoring equipment IV catheter and fluids as required 5888H - Veterinary Dental Nursing

Contaminated Surgery Veterinarians should in general avoid performing “dirty” dentals on an individual animal at the same time as major sterile surgery Bacteria entering the blood stream during dental work can lodge in the blood clots of the major surgery site. 5888H - Veterinary Dental Nursing

Safety Considerations Patient safety Operator safety Special considerations: Head movement > endotracheal tube induced tracheal trauma; if tracheal trauma: subcutaneous emphysema – if tracheal air escapes tracheal stricture – can appear days or weeks later. Head movement > tube twisting and kinking Head tilted up > fluids, blood, blood clots, calculus easily enter trachea. Cuffed tube > distal cuff still permits fluid to enter proximal trachea. Wet face, cold table/grill > greater heat loss and hypothermia Wet ET tube tie > loosens and falls out easily Risk of being bitten Aerosol in eyes Special anaesthetic procedures: Use cuffed endotracheal tube – just enough to occlude air leakage Ensure good grip on tube tie; might use: Rubber elastic band (not too tight on face) Drip tubing (not too tight on face or tube) Disconnect anaesthetic conduit when turning or moving animal. Don’t turn over the back (turn with legs kept underneath) – reduces chance of fluid entering trachea Slight incline for trachea Tilt table, or Use padding (eg bubble wrap) with more under shoulders, less under neck. Place absorbent wad in pharynx eg swabs, throat pads caudal to root of tongue REMEMBER TO REMOVE when finished – have a reminder check system – eg a marker on the ET tube when swab placed Ocular lubricant to protect eyes from aerosol Use mouth prop to protect and improve visibility – not too wide Heating mat, bubble wrap, water bottles. Some methods need care as may have risks of scalding and electrocution Head on a grill to keep it drier Monitor rectal temperature. Recovery: Place in lateral or sternal recumbency with the head and neck extended, preferably head below thorax Monitor temp, pulse, respiration, consciousness until able to maintain sternal recumbency Keep orifices clear, clean and dry Remove pharyngeal swabs Remove endotracheal tube at appropriate time Analgesics as indicated Report recovery problems Final grooming before discharge ^ Can use a rubber band to achieve a secure grip on a cuffed endotracheal tube. Need to take care however that tension around back of head or across muzzle is not excessive. Usual anaesthetic procedures: appropriate monitoring equipment IV catheter and fluids as required Veterinarians should in general avoid performing “dirty” dentals on an individual animal at the same time as major sterile surgery. Bacteria entering the blood stream during dental work can lodge in the blood clots of the major surgery site. 5888H - Veterinary Dental Nursing

Patient Safety Head movement > endotracheal tube induced tracheal trauma; if tracheal trauma: subcutaneous emphysema – if tracheal air escapes tracheal stricture – can appear days or weeks later. Head movement > tube twisting and kinking Head tilted up > fluids, blood, blood clots, calculus easily enter trachea. Cuffed tube > distal cuff still permits fluid to enter proximal trachea. Wet face, cold table/grill > greater heat loss and hypothermia Wet ET tube tie > loosens and falls out easily 5888H - Veterinary Dental Nursing

Use Cuffed ET tube Just enough to occlude air leakage 5888H - Veterinary Dental Nursing

Good grip on ET tube Ensure good grip on tube tie; might use Rubber elastic band (not too tight on face) Drip tubing (not too tight on face or tube) 5888H - Veterinary Dental Nursing

Good grip on ET tube 5888H - Veterinary Dental Nursing

Disconnect Tube When turning or moving animal 5888H - Veterinary Dental Nursing

Don’t turn over the back Turn under belly with legs kept underneath reduces chance of fluid entering trachea 5888H - Veterinary Dental Nursing

Slight incline for trachea Tilt table, or Use padding (eg bubble wrap) More under shoulders, less under neck Just think of airway position! 5888H - Veterinary Dental Nursing

Patient Positioning Options Dorsal Lateral Lateral: Most veterinarians and veterinary nurses prefer lateral recumbency. Place a towel or sandbag under the neck of the patient and tilt the head downwards, so as to ensure adequate drainage of saliva, blood and irrigating fluid. A cuffed endotracheal tube and pharyngeal pack (Metropack™) is essential to prevent aspiration. 5888H - Veterinary Dental Nursing

Dorsal Recumbency 5888H - Veterinary Dental Nursing Dorsal recumbency offers the advantage of superior visualisation of all aspects of the teeth, especially of the maxillary dentition. The patient can remain in the same position throughout the procedure in a standard fibreglass cradle. The operator needs access to a 180-degree arc at the end of the table - preferably seated on a wheeled chair. 5888H - Veterinary Dental Nursing

Lateral Recumbency 5888H - Veterinary Dental Nursing

Place absorbent wad in pharynx eg swabs, throat pads Past hump of tongue REMEMBER TO REMOVE when finished have a reminder check system – eg a marker on the ET tube when swab placed 5888H - Veterinary Dental Nursing

Pharyngeal Packing · 5888H - Veterinary Dental Nursing One of the main hazards of dentistry and particularly dorsal recumbency is fluid aspiration. A cuffed endotracheal tube and pharyngeal pack is essential to prevent aspiration. Ensure the palate is in a horizontal plane and lower the head end of the table. Place a towel or sandbag under the neck of the patient to hyper-extend the neck. Use a gag to maintain the mouth in an open position, but always beware of over-opening the mouth and straining the TMJ's over a long period of time. · 5888H - Veterinary Dental Nursing

Ocular lubricant To protect eyes from aerosol Artificial tears Lacrilube 5888H - Veterinary Dental Nursing

Care with Mouth Prop Is used to protect operator and improve visibility But not too wide! 5888H - Veterinary Dental Nursing

Warmth Consider Heating mat Bubble wrap Warm water bottles Some methods need care as may have risks of either scalding and/or electrocution 5888H - Veterinary Dental Nursing

Head on a grill To keep body and face drier 5888H - Veterinary Dental Nursing

Monitor Temperature Usually rectal temp measured 5888H - Veterinary Dental Nursing

Recovery Place in lateral or sternal recumbency with the head and neck extended, preferably head below thorax Monitor temp, pulse, respiration, consciousness until able to maintain sternal recumbency Keep orifices clear, clean and dry Remove pharyngeal swabs Remove endotracheal tube at appropriate time Analgesics as indicated Report recovery problems Final grooming before discharge 5888H - Veterinary Dental Nursing

Operator Safety What operator safety precautions shown here? Considerations: Risk of being bitten Calculus flicked into eyes Aerosol in eyes > possible conjunctivitis Large numbers of bacteria in aerosolised water droplets > possible inhalation and bacterial pneumonia Build up of debris on the skin or under the fingernails. Calculus debris may be flicked into eyes. Moisture contaminates clothing (hospital hygiene). Posture - scaling and polishing teeth can be a lengthy procedure that requires the operator to be in one position for a period of time. Often, dental procedures are performed at a dental station, a stainless steel bath on top of which a grill is placed on which the patient is positioned. As the dental station is usually of a fixed height, the operator should sit on an adjustable stool, which will allow them to sit comfortably without 'stooping'. Fatigue or back pain can lead to loss of concentration, which in turn may extend the length of the procedure and compromise the patient. Sharps. Many dental instruments must be sharp in order to be effective. Knowledge of their correct usage is essential. Anaesthetic gases. Need to protect the operator from waste anaesthetic gases. Lightly anaesthetised animals can bite operator Electrical heating mats – electrocution Precautions to take: Face mask** - discard after use, quality type, well fitted Gloves Eye protection – goggles or visor Cap Apron - waterproof Stool - adjustable 'Sharps' container – dispose of scalpel blades and burs Well-fitting endotracheal tube Anaesthetic circuit/system is free of any leaks Adequate scavenging system. Mouth prop – to prevent animal biting on fingers Use heating mats that are safe in presence of water (i.e. well insulated if electrical) 5888H - Veterinary Dental Nursing

Risk of being bitten Especially under light GA Use a mouth prop 5888H - Veterinary Dental Nursing

Eye protection . Risks Protection Calculus flicked into eyes Aerosol in eyes (possible conjunctivitis) Protection Full head visor Goggles or glasses 5888H - Veterinary Dental Nursing

Pneumonia Large numbers of bacteria in aerosolised water droplets These small droplets float deep into lungs Possible bacterial pneumonia Use face mask Quality type, well fitted But discard after use 5888H - Veterinary Dental Nursing

General contamination Build up of debris on the skin or under the fingernails Moisture contaminates clothing (hospital hygiene) 5888H - Veterinary Dental Nursing

Posture Often a lengthy procedure in fixed posture Use adjustable stool 5888H - Veterinary Dental Nursing

Sharps Discard of scalpel blades, needles, old burs into sharps container Care with handling sharp instruments 5888H - Veterinary Dental Nursing

Anaesthetic gases Usual scavenging systems Good fittings required if patient movement 5888H - Veterinary Dental Nursing

Electrocution Electric heating mats Faulty electric dental equipment 5888H - Veterinary Dental Nursing

Other protection Gloves Cap Apron - waterproof 5888H - Veterinary Dental Nursing

The End 5888H - Veterinary Dental Nursing