Veterinary Nursing Journal

ISSN: 1741-5349 (Print) 2045-0648 (Online) Journal homepage: https://www.tandfonline.com/loi/tvnj20

Brachycephalic anaesthesia, part 3: the post-

anaesthetic period

Courtney Scales & Niamh Clancy

To cite this article: Courtney Scales & Niamh Clancy (2020) Brachycephalic anaesthesia,
part 3: the post-anaesthetic period, Veterinary Nursing Journal, 35:1, 16-18, DOI:
10.1080/17415349.2019.1694736

To link to this article: https://doi.org/10.1080/17415349.2019.1694736

Published online: 13 Jan 2020.

Submit your article to this journal

Article views: 50

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=tvnj20
Clinical

Brachycephalic
anaesthesia, part 3: the
post-anaesthetic period
Courtney Scales  DipVN, NCert(Anaesth), RVN
Niamh Clancy  Dip AVN (Small Animal), DipHE, CVN, Dip
VN, PGCert VetEd, FHEA, RVN

Anaesthesia RVN, Queen Mother Hospital for Animals, Hatfield, AL9 7TA, UK
Courtney Scales DipVN,
NCert(Anaesth), RVN ABSTRACT: This article covers the post-anaesthesia period considerations for
brachycephalic breeds and discusses extubation timing, sedation and patient
Courtney is originally from New Zealand, monitoring. It follows the previous articles on pre-anaesthesia and peri-anaesthetic
where she qualified as a Veterinary Nurse considerations of these dogs.
in 2010 and worked in a number of small
animal clinics in Auckland. An anaesthesia Keywords: anaesthesia; brachycephalic; BOAS; BAS
passion took her to a large referral hospital
in Australia in 2015. She has been working
at the Royal Veterinary College since 2017. Introduction potential regurgitation fluid to be pulled
from the airway. The head should remain
Email: cscales@rvc.ac.uk Recovery of anaesthesia for brachycephalic
supported and the tongue pulled forward to
patients comes with a high risk for upper
open the airway. A roll of tape or bandage
respiratory obstruction, especially following
wedged between the canines or incisors can
airway surgery (Downing & Gibson, 2018),
be used as a gag to keep the mouth open as
and it is clear that these patients need more
seen in Figure 2.
intense nursing care in the recovery period.
A study conducted by Brodbelt et al. (2008)
While it is desirable for the ETT to remain
identified that the anaesthesia recovery
in place as long as possible to maximise
period is the most likely time for mortality;
oxygenation and airway patency (Fawcett
early detection of problems and adequate
et al., 2018), delayed extubation can cause
sedation where necessary can greatly
regurgitation. If this occurs the head should
decrease the risk of anaesthetic morbidity
be lowered to allow the contents to drain
and mortality during this time.
from the mouth, suctioned if possible
and cleared of any regurgitation material
Niamh Clancy Dip AVN (Small Patient positioning (Mosing, 2016).
Animal), DipHE, CVN, Dip VN, With the sedative effects of anaesthesia Post-extubation observations should
PGCert VetEd, FHEA, RVN drugs, many brachycephalic breeds appre- include monitoring for signs of dyspnoea;
ciate having their head and upper body ele- increased respiratory rate and effort, or
Niamh graduated from University College vated with a wedge or rolled up towels as
Dublin with her Diploma in Veterinary progressive stridor. Snoring, flaring of the
this position is similar to their compensa- nostrils or a paradoxical breathing pattern
Nursing in 2011. She then moved to the tory wide foreleg stance when they are fully
UK and worked in hospitals across London awake, known as an orthopneic stance,
while studying for her Advanced Diploma allowing them to take fuller breaths as seen
which she obtained from Myerscough in Figure 1.
College in 2015. She currently divides
her time as an anaesthesia nurse at the
Queen Mother Hospital for Animals and Extubation
as a Clinical Educator in Anaesthesia for In anaesthesia recovery, the patient should
the veterinary nursing school at the Royal be positioned in sternal recumbency with
Veterinary College. She recently obtained the head supported and the endotracheal
her Certificate in Veterinary Education. tube (ETT) cuff still inflated. Once the
Email: nclancy@rvc.ac.uk patient has started to swallow and demon-
strate airway control or no longer tolerates
the ETT, the cuff can be partially deflated
and the ETT can be removed; leaving a a 
Figure 1. Support in sternal recumbency
DOI: 10.1080/17415349.2019.1694736 small amount of air in the cuff allows any to allow fuller breaths.

Page 16 • VOL 35 • January 2020 • Veterinary Nursing Journal © 2020 British Veterinary Nursing Association (BVNA)
 Clinical
can signify that the patient is breathing Pulse oximeter Capnography
against a partially or fully closed airway. If
After extubation, oxygen saturation (SpO2) Capnography can be used once the patient
this happens, extend the neck and pull the
should be monitored for any signs of desat- has been extubated as seen in Figure 5. The
tongue forward as mentioned previously
uration (SpO2 < 95%) and hypoxia. This capnography sampling line (without the ET
(Mosing, 2016).
may be caused by partial airway obstruction tube connector) can be placed in front of one
or an inability to maintain saturation on of the patient’s nostrils which determine if
In the authors’ experience, some brachy-
room air of 21% oxygen (Adshead, 2014). there is airflow through stenotic airways
cephalic breeds snort and reverse sneeze
Due to the increased length of brachyce- when the patient prefers to breathe through
immediately after extubation as they try to
phalic breeds’ tongues, the pulse oximeter their nose. End tidal carbon dioxide
breathe through their nose; briefly holding
probe is well tolerated long into the recov- (ETCO2) monitoring can also be performed,
the nostrils closed will encourage them to
ery period as seen in Figure 4. If the SpO2 however there are some limitations with this
take a large breath through their mouth
drops below 93%, supplementary oxygen technique; readings may be inaccurately low
and dislodge the soft palate. As extubation
can be delivered via flow-by, a face mask if due to dilution from room air. As mentioned
of brachycephalic dogs is probably one of
tolerated or by placing the patient into an in the previous article, brachycephalic
the highest risk-associated periods of their
oxygen kennel. However, as brachycephalic patients tend to have a higher ETCO2. With
anaesthesia (Bradbrook, 2016), the team
breeds commonly have a lower Partial these limitations, the readings should be
must always be prepared to re-anaesthetise
Pressure of Oxygen (PaO2), they may not used as a trend and concerns should arise if
and re-intubate the patient if there are signs
‘saturate’ above 95% with pulse oximetry the ETCO2 continues to rise.
of respiratory obstruction. The same size (SpO2) while breathing room air after extu-
ETT that was originally placed and one size
bation. A pre-anaesthesia SpO2 may give a
smaller, anaesthesia induction agent and a
better indication of expectations during Sedation post anaesthesia
laryngoscope should be prepared close
recovery. As mentioned in article two, sedation pro-
to the patient during the recovery period
vided within the premedication drugs can
(Downing & Gibson, 2018) as shown in
help provide a smooth and quiet recovery.
Figure 3. Temperature In the authors’ experience, brachycephalic
Moderate hypothermia can be defined as a patients who are anxious are more like to
temperature of 34.0–36.5  °C (Redondo quickly become cyanotic and have respira-
et al., 2012). Hypothermia is known to tory distress, therefore the provision of
cause shivering, prolong recoveries, cause sedation for these patients is favoured.
coagulation deficiencies and impair platelet Suggested sedation doses can be found in
function (Levensaler, 2010). Normally, the premedication section of article two and
hypothermic patients are actively warmed can be given prior to recovery if they were
in the recovery phase to decrease the time not used as premedication. The flowchart
it takes to return to normothermia. shown in Figure 6 offers a suggestion of
However, the use of heating devices should when the RVN and veterinary team should
be used with caution when recovering intervene, with suggested actions that can
brachycephalic patients; even a return to be taken.
normothermia can cause excessive panting
which could cause vibration of pharyngeal
soft tissue leading to laryngeal swelling, Discharge
a 
Figure2. Use a roll of tape to keep the potentially causing airway obstruction. It Almost half of anaesthesia related deaths in
mouth open. should be decided at what point the patient dogs happen postoperatively, with most of
is actively warmed to in order to avoid shiv-
ering, but also avoiding excessive panting.
The authors suggest that a brachycephalic
patient with a temperature <36 °C is actively
warmed until they reach this temperature.
Patients that are shivering should have their
SpO2 monitored with flow by oxygen avail-
able as shivering can increase oxygen
consumption.

a 
Figure 3. A tray containing everything a 
Figure 5.Using a side stream capnography
required for emergency tracheal intubation a 
Figure 4. A pulse oximetry probe on a attachment to assess the patency of each
close to the patient. bulldogs tongue in the recovery period. nostril.

© 2020 British Veterinary Nursing Association (BVNA) Veterinary Nursing Journal • VOL 35 • January 2020 • Page 17
Clinical

a 
Figure 6. Thisflowchart can guide the RVN on when to alert the veterinary team to intervene with a brachycephalic recovery in relation
to increased respiratory effort.

them occurring in the first 3 hours (Brodbelt, they may be prone to corneal ulcers, so dis- confidential enquiry into perioperative small animal fatal-
ities. Veterinary Anaesthesia and Analgesia, 35(5), 365–373.
Pfeiffer, Young, & Wood, 2008) which sug- pensing an eye lubricant for postoperative doi:10.1111/j.1467-2995.2008.00397.x
gests it is advantageous to monitor these use may be beneficial.
higher risk patients for this length of time as Brodbelt, D., Pfeiffer, D., Young, L., & Wood, J. (2008). Results
a minimum after anaesthesia. If the patient It may be useful to have a discharge form/ of the confidential enquiry into perioperative small animal
fatalities regarding risk factors for anaesthetic-related death
was in any form of respiratory distress post post-operative handout that is specific to in dogs. Journal of the American Veterinary Medical Association,
operatively, or required emergency surgery brachycephalic breeds which explains to 233(7), 1096–1104. doi:10.2460/javma.233.7.1096
for airway obstruction, then they should not the owner what the signs of dyspnoea is
Downing, F., & Gibson, S. (2018). Anaesthesia of brachycephalic
be left unattended for the first 12 hours as and has the information of an emergency dogs. The Journal of Small Animal Practice, 59(12), 725–733.
many of these patients will require re-intu- practice close by. doi:10.1111/jsap.12948
bation. After Brachycephalic Obstructive
Fawcett, A., Barrs, V., Awad, M., Child, G., Brunel, L., Mooney, E.,
Airway Syndrome surgery (rhinoplasty,
staphylectomy etc.) soft tissue swelling can
Conclusion … McGreevy, P. (2018). Consequences and management of
canine brachycephaly in veterinary practice: Perspectives from
persist for a few days (Fawcett et al., 2018). These patients require intense nursing post Australian veterinarians and veterinary specialists. Animals,
anaesthesia and a designated RVN for 9(1), 3. doi:10.3390/ani9010003
recovery may be advantageous.
Many anaesthesia drugs like opioids, ace- Jolliffe, C. (2016). Ophthalmic Surgery. In T. Duke-Novakovski,
promazine and volatile agents can have M. de Vries and C. Seymour (Eds.) BSAVA Manual of Canine and
long lasting effects on pharyngeal muscle Disclosure statement Feline Anaesthesia and Analgesia, 3rd ed. (p. 261). Gloucester:
British Small Animal Veterinary Association.
tone (Mosing, 2016), causing relaxation of No potential conflict of interest was
soft tissue structures that may cause air- reported by the authors.
Levensaler, A. (2010). Monitoring: Pulse oximetry and tem-
perature, and hands-on. In S. Bryant (Ed.), Anaesthesia for vet
way obstruction. It is important to con-
technicians (pp. 190–207). Ames, IA: Blackwell.
sider their duration of action in relation to References
the discharge appointment with the client. Mosing, M. (2016). General principles of perioperative
However, if the brachycephalic patient is Adshead, S. (2014). Reducing the risk of anaesthetic com- care. In T. Duke-Novakovski, M. de Vries and C. Seymour
plications in patients with brachycephalic obstructive airway (Eds.), BSAVA Manual of Canine and Feline Anaesthesia and
stressed postoperatively, an early discharge syndrome. The Veterinary Nurse, 5(2), 78–87. Analgesia, 3rd ed. (pp. 15–20). Gloucester : British Small
from the veterinary practice may be more Animal Veterinary Association.
beneficial. Opioids can also reduce tear pro- Bradbrook, C. (2016). Recovering a brachycephalic patient. In
BSAVA Congress, Birmingham, p. 447. Redondo, J., Suesta, P., Serra, I., Soler, C., Soler, G., Gil, L., &
duction for up to 36 hours (Jolliffe, 2016) Gómez-Villamandos, R. (2012). Retrospective study of the
and as brachycephalic breeds have reduced Brodbelt, D., Blissitt, K., Hammond, R., Neath, P., Young, prevalence of postanaesthetic hypothermia in dogs. Veterinary
corneal sensory nerve fibres (Mosing, 2016) L., Pfeiffer, D., & Wood, J. (2008). The risk of death: The Record, 171(15), 374–374. doi:10.1136/vr.100476

Multiple Choice Questions

1. 
What position is recommended to (b) The airway is partially/fully closed (d) Within 12-24 hours post anaesthesia
recover a brachycephalic patient in? (c) They are sleeping happily 4. What should brachycephalic patients
(a) Dorsal (d) They are becoming hyperthermic be discharged from the practice with
(b) Any lateral post anaesthesia?
3. When do 50% of anaesthesia-related
(c) Tilted head down deaths occur in the anaesthesia recov- (a) Eye lubrication
(d) Sternal ery period? (b) A tin of low-fat food
2. What does flaring of the nostrils and a (a) There is no risk, it is a peri-operative (c) Wearing a harness
paradoxical breathing pattern signify concern (d) Pet shampoo
after extubation? (b) Within 3 hours post anaesthesia
(a) The patient is taking deep breaths (c) Within 3-12 hours post anaesthesia

For the answers to the MCQs, please go to: http://www.bvna.org.uk/publications/veterinary-nursing-journal

Page 18 • VOL 35 • January 2020 • Veterinary Nursing Journal © 2020 British Veterinary Nursing Association (BVNA)