Running head: CRUCIATE REPAIR

Tibial Plateau Leveling Osteotomy:

The Complete Surgical Nursing Experience
Rebecca M. England
VETE 4325 Companion Animal Anesthesia and Surgical Nursing
Tarleton State University

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Blue is an 8-year-old male-neutered Malamute mix. He was neutered as a puppy. He

currently weighs 96 pounds, with an ideal body condition score of 5/9. He has been seen by our
veterinary staff throughout his life, since he was neutered. He has a history of elbow dysplasia
since 2014, but has otherwise been considered healthy prior to this examination. One week ago,
he presented 5/5 lame on his left hind limb.
Blues physical exam findings:
General attitude: BAR, appears happy to be at the veterinary hospital; interactive with staff
Overall appearance: Normal
Dehydration Assessment: Normal (based upon skin tent)
T: 100.1 F P: 88 bpm RR: 10 bpm CRT: 1 sec. MM: pink / moist
Eyes: Clear, no discharge
Ears: Free of debris, ectoparasites, and TM intact
Lymph nodes: All normal size, shape, texture (submandibular, popliteal, prescapular palpated)
Respiratory: No abnormal sounds auscultated, no nasal discharge
Cardiovascular: No murmurs auscultated, strong pulses, no pulse deficit heard
Oral cavity: Mild calculi and gingivitis present, had dental prophylaxis and care one year ago
Integument: Healthy coat/skin appearance
Musculoskeletal: 5/5 lame L hind. Toe-touching per owner less than 25% of the time at home. 3legged at time of exam
Gastrointestinal: No abnormalities palpated
Genitourinary: Normal
Nervous system: PLRs normal, normal CP (conscious proprioception). Mentation normal. Full
exam not performed
After the physical examination and performing two-view radiographs as requested by the
veterinarian, it was determined that Blue had torn his cranial cruciate ligament. His radiographs
are seen below:

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To correct the problem, Blue would need Tibial Plateau Leveling Osteotomy (TPLO) surgery,
ideally, as soon as possible. The procedure, the post-operative care, and the estimate were
extensively discussed with the owner and she consented to scheduling surgery for the following
week. In preparation, 5 ml of blood was drawn from his right jugular vein for a preanesthetic
panel, to check for dehydration, anemia, kidney and liver function, and systemic infection. To
keep him comfortable until surgery, Blue was prescribed a course of 100 mg carprofen to take by
mouth with food every 12 hours until the surgery. I also instructed her to not offer Blue any food
after 8 pm the night before the procedure, but that water was permitted until his drop-off time at
7:15 am. This was to assist in the prevention of regurgitation or vomiting during the procedure.
Upon drop-off on Tuesday morning, I re-discussed the estimate with the owner. I
explained to her what exactly the procedure would entail pre-anesthetic exam, I.V. catheter
placement, premedication, and anesthetization for surgery. I also explained that while the surgery
would be completed this morning, Blue would spend the night in the hospital so that he could be
monitored for complications, for 24 hours after surgery. The owner also requested that we trim
his nails under anesthesia. The owner also stated that she followed Blues food instructions as

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discussed previously, and that he was not given any carprofen that morning. She had no further
questions, signed the necessary consent forms, and we started the procedure.
Upon pre-anesthetic exam:
General attitude: BAR
Dehydration Assessment: Normal (based upon skin tent)
T: 100.0 F P: 90 bpm RR: 10 bpm CRT: 1 sec. MM: pink / moist
Respiratory: No abnormal sounds auscultated, no nasal discharge
Cardiovascular: No murmurs auscultated, strong pulses, no pulse deficit
Musculoskeletal: 3/5 lame L hind on pain management, using limb to walk; toe-touches at rest
It is also important to note that Blues preanesthetic bloodwork results were completely within
normal limits, and was released to have anesthesia.
I then placed a 20-gauge I.V. catheter is his right cephalic vein after shaving the hair and
prepping the area. A catheter guard was placed over his catheter to prevent any damage from
possible licking or chewing.
As per his veterinarians instructions, I then premedicated Blue with 1 ml hydromorphone
and 0.04 ml acepromazine subcutaneously (SQ). He also received 0.92 ml atropine SQ, as he
was heavily drooling. I calculated the drug doses for his premedications as follows, referencing
Plumb:
2 mg/ml hydromorphone dosed at 0.05 mg/kg:
96 # / 2.2 # = 43.6 kg
43.6 kg * 0.05 mg/kg = 2.1 mg
2.1 mg / 2 mg per ml = 1 ml given SQ
10 mg/ml acepromazine dosed at 0.01 mg/kg:
96 # / 2.2 # = 43.6 kg
43.6 kg * 0.01 mg/kg = 0.43 mg
0.43 mg / 10 mg per ml = 0.04 ml given SQ

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A 75 mcg transdermal fentanyl patch was placed on the plantar surface of the metatarsals of
Blues right hind foot, after this area was surgically shaved. After I held the patch to his skin for
one to two minutes, I covered it with a light bandage and a description label. Per the
veterinarians instructions, I also gave 100 mg carprofen SQ, as the owner did not give any that
morning. These additional medications provided him with additional pain management; he
received multimodal analgesia for this particular procedure.
While I was waiting for Blue to become sedated from his premedications, I set up a few
things. I printed two anesthetic monitoring sheets. I made sure the oxygen tank had enough
oxygen for our procedure, and that the tank was turned on. After attaching a standard F-circuit
and a 4-liter reservoir breathing bag, I leak-tested the anesthetic machines, both in the induction
area and the operating room (OR). I collected the necessary packs and other supplies needed for
this procedure. In doing so, I finished setting up the OR and turned on the heated surgical table.
The anesthetic of choice for this patient was to induce with 2.4 ml ketamine and 2.4 ml
midazolam intravenously (IV); this protocol was chosen to support blood pressure during this
lengthy procedure and so that additional pain management could be provided via a ketamine
constant rate infusion (CRI). I then flushed the catheter with 0.3 ml of sodium chloride. I
intubated him with a size 11.5 mm endotracheal (ET) tube, inflated the cuff appropriately (as I
listened for a leak), and attached his tube to the rebreathing circuit that was set up. Right away,
his anesthetic gas levels were initiated at 2% isoflurane and 5 L/min of oxygen for the first five
minutes. I rotated him into right lateral recumbency, auscultated his heart and lungs, and palpated
his femoral pulses. All was within normal limits (WNL). During this time, I lubricated his eyes,
hooked up all of his monitoring equipment (to include: HR, RR, SpO2, Co2, BP, and core
temperature) and trimmed all of his nails per the owners request. I applied latex gloves to all of

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his feet, except the left hind. I also covered his body with bubble wrap and blankets. This
assisted in reducing heat loss during anesthesia. Once he was in Stage III, Plane II of anesthesia,
he was reduced to 1.75% isoflurane and 1.5 L/min of oxygen. His vitals and other readings were
continuously monitored throughout the procedure, but were recorded upon his anesthetic record
every five minutes. I calculated the drug doses for his induction as follows, referencing Plumb:
100 mg/ml ketamine dosed at 5.5 mg/kg:
96 # / 2.2 # = 43.6 kg
43.6 kg * 5.5 mg/kg = 240 mg
240 mg / 100 mg per ml = 2.4 ml given IV
5 mg/ml midazolam dosed at 0.28 mg/kg:
96 # / 2.2 # = 43.6 kg
43.6 kg * 0.28 mg/kg = 12.2 mg
12.2 mg / 5 mg per ml = 2.4 ml given IV
As soon as induction was complete, Blue was placed on a ketamine CRI. This was
created using one liter of Lactated Ringers Solution (LRS) and 60 mg of ketamine mixed in. He
received 10 ml/kg/hr of fluids at a rate of 436 ml/hr. This provided a ketamine dose of 10
mcg/kg/min. I calculated his fluid rate, seen below:
96 # / 2.2 # = 43.6 kg
43.6 kg * (10ml/kg/hr) = 436 ml/hr
Blue also received a dose of IV cefazolin at 100 mg per 10 pounds of body weight. At this time, I
administered 9.6 ml of cefazolin. I calculated his dose, seen below:
100 mg/ml cefazolin:
96 # * (100 mg/10# of BW) = 960 mg

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960 mg / (100 mg/ml) = 9.6 ml cefazolin

In In addition to ensuring Blues safety while under anesthesia, it was also my job to
prepare his leg for surgery and assist the veterinarian during the procedure. As I monitored him, I
also began to surgically shave the hair from his left hind leg, from the midline of his back down
to his metatarsals, including the entire circumference of the limb. When finished, I fixed a stirrup
from his metatarsals to his toes, using waterproof bandaging tape. The purpose of this was so that
his leg could be hung from the ceiling in the OR during the preparation phase. Before entering
the OR, I made sure my scrubs were free of hair and debris, changed my shoes, and applied a cap
and face mask. This helped ensure cleanliness and asepsis within the OR.
With assistance, I then moved Blue to the OR. All monitoring equipment was hooked up
and the ketamine CRI continued to be administered. The patient was positioned in dorsal
recumbency and I fixed his leg, using the stirrup, to the hook on the ceiling. Finally, warming
devices were placed on the patient, including an IV fluid warmer and a warm air circulator.
While the veterinarian prepared for surgery, I prepped Blues leg with chlorhexidine scrub and
isopropyl alcohol, using a standard aseptic technique.
I then tied the veterinarians surgical gown on the backside, and when he was ready, I
opened the main surgical pack. In doing so, I cautiously observed the sterile field boundaries, so
as to not contaminate them. The veterinarian immediately started to drape the surgical field. I
opened a pouch that contained sterile vetwrap, so that he could touch the lower limb without
becoming contaminated. As he did this, I cut the stirrup from the toes and from the ceiling, to
release the limb. I then appropriately handed him a fenestrated leg drape, a large table drape, and
a size 10 surgical blade.

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I continued to monitor Blue under anesthesia as the procedure continued, and my other
duties were endless. They included:
1.
2.
3.
4.
5.
6.

Passing instruments and other items to the surgeon and scrubbed-in assistant
Adjusting the light over the surgical field
Addressing any and all patient needs
Monitoring and adjusting IV fluid administration
Keeping the surgical site moist with saline
Logging controlled drugs and entering procedural charges and inventory into the
patients account
7. Recording the screw sizes and locations (six of them) within the plate
8. Taking pictures of the procedure as requested
9. Performing various calculations as needed
Lastly, as the veterinarian was finishing up, I handed him a skin stapler. He then placed 15
staples to close the skin incision.
Just before anesthetic recovery, additional analgesia was administered. Per the
veterinarians instructions, I gave an additional 1 ml of hydromorphone SQ. In order to assess the
placement of the plate and screws within Blues leg, it was also necessary to take post-operative
radiographs. After transfer from the OR to the radiology room, two views of his left stifle were
taken, a lateral view and a dorsoventral (DV) view. All hardware appeared to be properly placed,
according to the veterinarian. Blues post-operative radiographs are seen below:

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Immediately after radiography, I prepared Blue for recovery. I turned off the isoflurane
anesthetic gas and gave him 100% oxygen to breathe and I gave him two consecutive sighs to
fully inflate his lungs with fresh oxygen. Once he was breathing well on his own, and his
reflexes returned (palpebral, pinna flick, jaw tone, and complete multiple swallows), I deflated
his ET tube cuff and unhooked him from all of the monitoring equipment, as well as his IV
fluids. I sat him up in sternal recumbency and extubated him near the oxygen source in case a
problem were to arise. His TPR was normal post-anesthesia, and then he was placed in a kennel
to be closely monitored and observed for several hours. He recovered comfortably and quietly,
with no complications. Since I was the person providing his nursing care, I also performed his
evening treatments once he was able to walk. These included:
1.
2.
3.
4.
5.

Walk outside to relive himself

Offering small amounts of food and water
Administering oral amoxicillin and carprofen per the veterinarian instructions
Icing his stifle
Fitting him for an Elizabethan-collar (e-collar) to prevent trauma to the surgery site while
unsupervised overnight
Once the OR was no longer being used, it was time to clean up. All disposable materials

were discarded. All instruments and surgical tools were moved back to the surgical preparation
area, to be soaked, washed, lubricated, and rewrapped. Once ready, they were all autoclaved. The
OR was cleaned up appropriately; all items were put away, and then all surfaces, including the
floors, were dusted and swept, and then disinfected.
The following morning after surgery, I attended to Blues needs. Upon arrival, I noticed
that he had removed his e-collar overnight, and had caused some damage to his surgery site. I
called the veterinarian in to examine Blue, as he had removed all the external staples that were
placed during surgery. Upon examination, the rest of the surgery site appeared to be intact. After
owner consent was obtained, the veterinarian instilled a local anesthetic block at the incision site

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10

with lidocaine using syringe with a 25-gauge needle. I then gently cleansed the wound with
dilute chlorhexidine. After the block was effective, 15 new staples were placed to hold the
incision closed.
After this had been addressed, I administered Blues oral medications and iced his stifle
for ten minutes. He was then able to be released into the care of his owner. When she came to
pick him up, I discussed all discharge instructions and medications with her. It was also stressed
that Blue needs to wear an e-collar at all times, unless being directly and completely supervised.
He needed his first follow-up visit two weeks later, to assess his assess the progress of his
healing and remove the staples if ready. She scheduled this recheck appointment as instructed.
After no further questions, Blue was released.

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11
References

Photographs retrieved with permission from Blues file

Plumb, D. C. (2011). Plumbs Veterinary Drug Handbook, 7th ed. PharmVet Inc.
Tear, M. (2012). Small Animal Surgical Nursing: Skills and Concepts, 2nd ed. St. Louis, MO:
Elsevier Mosby.
Thomas, J. A. and Lerche, P. (2011). Anesthesia and Analgesia for Veterinary Technicians,
4th ed. St. Louis, MO: Elsevier Mosby.