Transcript Anesthesia Angst

Kelly Lynn Cronin, MBA, BS, PHR, VTS
(ECC), RVT
Operations Manager Advanced Animal Hospital Group
Owner/CEO Success Strategies Veterinary Consulting
At: http://www.wallpaperden.com/dog-face-3.shtml
Second Rule of Anesthesia
Never Let Go of a Closed Pop Off Valve
Safe Anesthesia Starts Before Your
Patient Arrives
Pre-Anesthesia Requirements
•General Consent Forms
•Discussion of Risks
•Physical Examination
•Medications & Fluids
•Pre-anesthetic tests
•Specific Pre-anesthetic Protocols
At: http://www.wallpaperden.com/dog-face-3.shtml
Food should be withheld for 12 hours prior to admission
in normal cats and dogs over age 4 months.
Why?
Exceptions?
How do we mitigate hypoglycemia in these patients?
How do we test for BG during anesthesia?
J Am Anim Hosp Assoc 2011; 47:---–---. DOI 10.5326/JAAHA-MS-5846
At: http://www.wallpaperden.com/dog-face-3.shtml
Discuss Anesthesia Concerns with the
Owner
Discuss the Risks of Anesthesia
Blood samples should
be drawn prior to
premeds if it is not
excessively stressful
to the patient as premeds may influence
the results of certain tests
Example – Acepromazine can decrease
patient PCV up to 30%
Pre-anesthetic medications should be administered:
-30 to 45 minutes prior if given SQ.
-15 to 20 minutes prior if given IM
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• Acepromazine
• A phenothiazine tranquilizer
–No analgesic properties
–Addition of an opioid reduces the
acepromazine dose and the likelihood of
hypotension or excessive sedation
–Ace is no longer a concern with seizure
patients
Garner, J., Kirby, R. and Rudloff, E. (2004), THE USE OF ACEPROMAZINE IN DOGS WITH A HISTORY OF
SEIZURES. Journal of Veterinary Emergency and Critical Care, 14: S1–S17. doi:10.1111/j.1476-4431.2004.t0127-04035.x
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• Atropine /Glycopyrrolate
–Heart rate increase
–Decrease secretions
–Parasympatholytic
–Anticholinergic
• Difference glycopyrrolate and
atropine?
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• Butorphanol
– Opioid
• Butorphanol adds a short acting analgesic
effect
• Recommended use
–Butorphanol has an antagonistic effect
when used with mu agonist opioids such
as morphine, hydromorphone, fentanyl,
or oxymorphone
–More effective for sedation than for
analgesia
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• Opioids
–Many options morphine,
hydromorphone, fentanyl,
buprenorphine or oxymorphone
• Varied duration of action
• Effective for sedation and analgesia
–Can cause vomiting
–Can cause respiratory depression
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ASA anesthesia guidelines
1. Healthy
2. Mild systemic disease.
3. Severe systemic disease not
incapacitating.
4.Incapacitating disease
5.Moribund patient not expected
to live
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What constitutes anesthesia ?
Anesthesia is a temporary induced state with one or more
of analgesia , paralysis , amnesia, and unconsciousness.
• What warrants intubation?
• What warrants a catheter?
• What warrants an emergency drug sheet?
http://csuvth.colostate.edu/emergencydrugcalculator/
Set Yourself up for Success
-Leak test your machine prior to every use
-Care for ET Tubes correctly
-Check ET tubes prior to use
-Stylets?
-Cuff inflation
- Use the right sized tubes and system for your patient
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Cautionary Tale
Most Dangerous Periods
During Anesthesia?
Induction
Recovery
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Anesthesia monitoring
• Parameter times?
• 1st route of parameter correction
• Time required to change anesthetic depth
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Got O2?
•Discussion re-breather vs. non re-breather
•Discussion dead space
•Flow rate
•Flush Valve
•Lung inflation
Anesthesia Monitoring
End Tidal CO2
• First and best warning
•Better at assessing respiratory quality than SPO2
•Great warning for faulty equipment
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Anesthesia Monitoring
Temperature
• Affects everything else
•Is affected by everything else
•Is all too often ignored
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Anesthesia Monitoring
Blood Pressure
• A must in small patients and cats
•>60 mm Hg MAP
•A dry kidney is a dead kidney
•Lasting effects
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Anesthesia Monitoring
Pulse Oximetry
• Gets the most love
•Deserves it least
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Best Anesthesia
Monitoring Device?
Surgical fluids
• Why are fluids so important during anesthesia?
• Vasodilation
• Surgical Rate
There are no safe anesthetic agents, there are no safe
anesthetic procedures. There are only safe
anesthetists.—Robert Smith, MDa
Etomidate
• Short acting intravenous
• Used for conscious sedation if not combined in
multi-modal induction
• Good for cardiovascular compromise
• Rapid onset of action
• Head traumaDecreases intracranial pressure and maintain a normal
arterial pressure
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Ketamine
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Pain Killer
Used alone elevates BP (stimulates circulatory)
Antidepressant
Agitation and confusion
Given IV/IM
• NMDA receptor antagonist or classified as dissociative
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Valium/Midazolam
• Benzodiazapine
• Profoundly
potent anxiolytic, amnesic, hypnotic, anticonvul
sant, skeletal muscle relaxant, and sedative
• Given IV/IM (valium stings)/rectal
• Rapid onset of action
• Flumazenil is the reversal agent
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Propofol
• Given IV
• Hypnotic/amnestic
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Rapid onset of action
Causes respiratory depression
Not much analgesic effect
Potential pain on injection
Vasodilation sometimes leads to lower BP
Serial use in cats is contra-indicated due to red blood
cell destruction/ 28 is also contra-indicated in cats
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Alfaxan
• Given IV for induction/IM for sedation
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Rapid onset of action
Rapid elimination
No extra-vascular tissue irritation
Consecutive days use is fine
Less respiratory depression
Not analgesic
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Isoflurane
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Halogenated Ether
Inhalation anesthetic
Mechanism of action is not understood
Analgesic
Muscle relaxant
Potent vasodilator
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Reversible Sedatives
Dexdomitor
-synthetic α2-adrenoreceptor agonist
-off label in cats
-reversed with antipamezol
-peripheral vasoconstriction
- bradycardia
light,sound and pain reactive
-hyperexcited dogs may have
reduced effects
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Reversible Sedatives
Xylazine
-Rompun
-synthetic α2-adrenoreceptor agonist
-makes cats vomit
-reversed with yohimbine
-sedative
-analgesia
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