Primum non Nocere, Veterinary Critical Care Consultancy

Primum non Nocere, Veterinary Critical Care Consultancy Primum non Nocere provides critical care, anaesthesia and pain management consultancy for busineses and institutions in the Veterinary field.

Advancing veterinary anaesthesiology, pain management and critical care to provide state of the art peri-operative and intensive care to animals. Continual education of veterinarians and veterinary technicians through consulting on location, presentations at congresses and symposia. Revive, teach and refine locoregional anaesthesia techniques as adjunct to general anaesthesia and in pain relieve i

n (critical ill) animals in veterinary medicine. Refine laboratory animal sciences with the institution of good quality anaesthesia and analgesia, as well as perioperative supportive care in research.

I agree with most of what my blogging colleague of medical anaesthesia is stating. However, being rmore than 22 years fu...
30/01/2024

I agree with most of what my blogging colleague of medical anaesthesia is stating. However, being rmore than 22 years fully committed to providing specialist level anaesthesia care, I found the most important growth involved switching from a drug oriented approach to a periprocedural goal oriented approach. In the latter, knowledge about physiology, pathophysiology, internal medicine (to assess if conditions are managed appropriately prior to anaesthesia provision), critical care and pre-emptive strategies to prevent or limit ischaemia/ reperfusion injury, allostatic compensation bandwidth/frailty, surgical procedure planned and surgical stress involved, risk of (chronic) post procedural discomfort and pain and deep respect for the body's ability to heal come together to formulate measurable goals you commit yourself to and keep working towards or maintain in the preoperative journey you undertake with the patient in your care. I frame this as total anaesthesia care which commences several days prior to the procedure and does not stop until several days after the procedure. I firmly believe that anaesthesiologists should be the orchestrator of the procedural patient journey, as they are uniquely qualified and committed to oversee the case from a patient (and client) centric approach.

Is your doctor an experienced anesthesia provider or a newbie? In my view, inexperienced anesthesia providers are more likely to:

As co-developer of the AVA accredited Dog and Cat Anaesthesia App, Primum non Nocere and myself, together with co-creato...
07/12/2023

As co-developer of the AVA accredited Dog and Cat Anaesthesia App, Primum non Nocere and myself, together with co-creators Matt Gurney and Lizzie Barker have received fantastic news from France! Our AVA/Dechra Dog & Cat Anaesthesia App managed to convert the nomination to actual Award for Best Innovation for (educational and practical) service for veterinary professionals at the French National Veterinary Innovation Awards, held at AVFAC last week!
I am very proud that the carefully balanced format combining preparatory reflection through the considerations on the one hand, and practical patient-tailored recipees for getting things done on the other is resonating so well within the (French) veterinary community.

This is solid advice from a trustworthy source. As with anaesthesia, planning and being prepared is everything......
22/11/2023

This is solid advice from a trustworthy source. As with anaesthesia, planning and being prepared is everything......

While your clients might want to bring their pets along when visiting family and friends, it's important they understand the importance of planning and preparation. ✈

Share this post with your clients! Learn more: https://msdmnls.co/49w5zhF

19/11/2023

I get this question from veterinary surgeons and nurses a lot: When I intubate a dog's trachea, the patient coughs a little. That is okay, right? (At least I know it is in the trachea).
Let's go back first to the goals of airway management:
1. Provide effective supportive oxygen therapy (FiO2 ≥ 0.3)
2. Provide a means to monitor pulmonary gas exchange as well as monitoring appropriate application of a technique (FGF) for the selected breathing circuit to prevent inhaling a gas mixture containing CO2.
3. Secure a patent airway irrespective of positioning
4. Provide a protected airway (taking over this function from the functional larynx in awake dogs)
5. Means to support pulmonary minute ventilation
This is best achieved bij placing an endotracheal tube with cuff (low pressure, high volume).
In order to place the ET tube, you were taught the correct method at University.
In practice I encounter a plethora of variations being applied, usually leaving out one or several steps, like no induction agent administered (only premedication), not using a light source/laryngoscope or omitting using a desensitising topical spray on the vocal cords.
With the stepwise approach given below, you will not only maximize success of endotracheal tube placement (on first attempt), but also keep airway and laryngeal trauma or temporary dysphonia to a minimum and postprocedural patient comfort optimal during swallowing and normal use of the larynx.
A. Check the patient file for demographic data, BCS, head/jaw/upper airway trauma/disease/symptoms and/or sleep apnea and previous anaesthetic records (ET tube size placed, remarks made on ease of intubation); Check cliënt adherence to vasted status in planned procedures. Postpone or discuss rapid sequence induction (risks/costs) when non-fasted (not further discussed here)
B. Prepare airway management -less or more elaborately- based on the predicted risks and actual pre-anarsthetic physical exam
C. Prepare 3 sequential ETtube sizes and (also 1 or 2 guarded ET tubes to be placed after CT Scan), do a visual inspection of ALL ET tubes and place them on a clean tissue. Inflate the cuff of ALL ET tubes and leave them for 5 min on the tissue to detect slow leaks of the cuff; do not forget to check tightness of the tube to circuit adaptor as well.
D. Deflate the cuffs prior to premedication or IV cannula placement.
E. Prepare appropriate topical anaesthesia and a laryngoscope, check lightsource/battery with intended blade to be used; Clean/disinfect the blade prior to induction.
F. Induce the patient, pre-oxygenate when still breathing with high flow O2 if not done so already
G.check for jaw tone and introduce the laryngoscope GENTLY to visualize the larynx. Assess laryngeal motility
H. Spray the larynx in this stage already if possible, and take the size of the rima glottis.This requires no slime/foreign matter being present of course.
I. Allow further increase of anaesthetic depth by allowing time or fractioned dosing of induction agent (continue pre-oxygenation even when not breathing)
J. Perform a full oropharyngeal inspection using the laryngoscope (do not forget to inspect under the tongue). Inspect and desensitize the laryngeal mucosa first, if not already done under H.
Remove any foreign matter using suction first, before desensitizing the larynx.
K. REMOVE/retract your laryngoscope when distracted or reaching for the ET tube
L. Check anaesthetic depth, type/rate of breathing and mucous membrane colour.
M. Place an appropriate size ET tube between the vocal cord, retract the laryngoscope and assess correct position of the ET tube by:
1. Observing tidal appearance of condensation during expiration (after manual breath if apneic) -note: coughing is NOT a desired assessment technique!)
2. Feel with your own cornea (very sensitive detector) that air flows TROUGH the lumen -note, the cuff is NOT inflated untill correct position is confirmed). Let an assistant gently yet briefly and quickly apply pressure on the thorax in non breathing patients to generate flow.
3. Connect the breathing circuit (O2 flow 1-2L/min depending on patient size
4.generate 20 hPa of in circuit pressure by squeezing the reservoir af and listen of air escaping alongside the ET tube.
5. Inflate the cuff gradually during the next 2 squeezes to 20hPa untill no leak is heard anymore
N. Fix the position of the ET tube to the patient as per local custom
O. Place a capnograph sensor as close to the ET tube as possible and give 3-5 appropriate manual breaths and observe the ETCO2. If going down to almost 0.5kPa (3,2 mmHg) the ET tube is in the oesophagus!
P. After confirming ETCO2 stays above 3.5 kPa (25 mmHg), your ET tube is endotracheally positioned
Q. Auscultate during 2-3 manual breaths ventrally cranial to the heart on the thorax for bilateral breathing sounds. If you do not hear breathing sounds, auscultate the stomach; if no sounds on the right, the ET tube is too far (in the carina).
R. In that latter case, deflate the cuff, retract the ET tube a bit and re-insufflate the cuff. Auscultate again and if satisfactory, refix the position of the ET tube as per local costum.

And now some good time catching up with work, my own    education as   recognized specialist in Anaesthesia and Analgesi...
25/03/2023

And now some good time catching up with work, my own education as recognized specialist in Anaesthesia and Analgesia together with friends from all corners of the world at the Clinical Pain Congress & congress in
After a 24 travel and first day of Congress, it is first time for restoring my neurotransmitter supplies. For this and
for some much needed catching up with projects, this comfortable suite with some views on Darling Harbour will do very nicely indeed for the coming 5 days!

Today, I am attending the first conference in the Netherlands on the Post Anesthetic Care Unit (PACU) in the Dutch Medic...
10/11/2022

Today, I am attending the first conference in the Netherlands on the Post Anesthetic Care Unit (PACU) in the Dutch Medical Care system. I hope to gain some insight in how to optimize the fast tracking of veterinary patients subjected to highly invasive surgical procedures.

26/07/2022

in a 4 kg toy breed discharged on the same day. Notice the tiny airbubble (subsequently removed) confirming arterial pulsations
Addendum: GDPR compliance was assured with obtaining owner consent for sharing this video on social platforms

Stand strong against unprovoked aggression. My utmost admiration and respect for Ukrainian veterinarians working under u...
09/06/2022

Stand strong against unprovoked aggression. My utmost admiration and respect for Ukrainian veterinarians working under unimaginable conditions.
(Association of Veterinary Anaesthetists (Ukrainian Small Animal Veterinary Association)

26/11/2021

The newly updated Dechra Dog & Cat Anaesthesia App, developed on a completely new platform is out. HUGE effort and accomplishment from especially Elizabeth Barker, with expert content input from Matthew Gurney and myself.
More protocols and improved functionality. There are plans for continuing improvements in future updates, as the new platform put time pressure on maximising content and functionality. Completely free to download in the Apple App Store (https://apps.apple.com/sr/app/dechra-dog-and-cat-anaesthesia/id1450472509) and Google Play Store (https://play.google.com/store/apps/details?id=com.anaesthesia.en)

For those veterinary medicine students in their clinical rotations and veterinary surgeons at the beginning of their cli...
29/08/2021

For those veterinary medicine students in their clinical rotations and veterinary surgeons at the beginning of their clinical carreer, the third edition of The Cutting Edge is now available as a free download. Apart from very useful and practical information on basic surgical techniques and bandaging (among others), this edition has a newly structured chapter (Ch 17) on the basics of (immediate) postoperative care and pain assessment & management.
Check it out via the link below!
https://globalveterinarysurgery.net/book/

The third edition of the Cutting Edge is out and free to download 5601_CuttingEdge3_Final_LR_082221Download

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