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MONITORING ANIMALS WITH THE USE OF INSTRUMENTATION These machines can be very useful, especially in the situations where the technician can’t always be with the patient through the entire procedure; however you should never completely rely on your machines The following can be monitored via machines: Blood pressure, Central Venous Pressure, Blood Gases, Pulse Oximetry, Capnography, and Electrocardiography ◦ Measures the electrical activity of the heart – NOT the mechanical activity. REMEMBER THAT THE EKG CAN CONTINUE EVEN IF YOUR PATIENT’S HEART IS NOT CONTRACTING. This is called ________________________________________ ◦ The complexes should be of normal configuration, consistent size, rate, and rhythm ◦ If the complexes look abnormal: Alert the Dr. Check the patient! Check the lead placement A cardiac arrhythmia is any pattern of electrical activity that differs from the healthy, awake animal MOST COMMON EKG ABNORMALITIES SEEN WHICH MUST BE ADDRESSED are: 1) ________________________________ ◦ Diagnosed when a patient’s HR under anesthesia is: >200 bpm in cat >180 bpm in small dog > 160 bpm in large dog ◦ Causes: Can be _________________ (atropine, ketamine), or response to surgical stimulation If animal is “huffing” during surgery if reflex activity is present or moving occurs, patient may be too “light” Can also occur in situations of ________________, ______________________, or high ______________ levels Pre-existing conditions of the heart, thyroid, anemia, shock (compensatory/early) ◦ Treatment: Emergency treatment can include applying pressure to the eyeballs 2) _______________________________ ◦ Diagnosed when patient’s HR under anesthesia is: < 60 bpm in large dog <70 bpm in small dog < 100 bpm in a cat ◦ Causes: Can be drug related (xylazine, dexmedetomidine, opioids) Increased anesthetic depth, hypoxia (late stages), hypothermia ◦ Treatment: Can give reversal agents or atropine Assess other parameters before deciding management 3) ________________________ ◦ Electrical impulse through the heart is not being transmitted efficiently. _______________________: There is a P wave for every QRS complex, but the P-QRS interval is prolonged _______________________: Some P waves are not followed by QRS complexes _______________________: The atria and ventricles are contracting independently. No normal relationship between P waves and QRS complexes 2nd and 3rd degree blocks can be seen after alpha-2-agonist administration & high vagal tone 4) _________________________________ ◦ Impulse arising from the ventricular muscle causing an uncoordinated heart contraction ◦ QRS complexes are wide and bizarre ◦ Causes: hypoxia, heart disease or trauma, electrolyte abnormalities, etc Epinephrine release can stimulate the formation of VPCs Don’t forcibly restrain an animal during the induction of anesthesia! 5) ______________________: > 3 VPCs in a row, more than 15 in one minute, or VPCs + falling blood pressure EMERGENCY!! Can be treated with __________________given IV 6) ________________________ ◦ Contraction of small muscle bundles within the atria or ventricles Atrial fibrillation No p-waves, high HR, normal QRS complexes Ventricular fibrillation Absence of QRS complexes CARDIAC ARREST IS IMMINENT ECG: Atrial Fibrillation Refers to arterial blood pressure _______________________Pressure – produced by the contraction of the ventricles as it propels blood through the aorta, pulmonary artery, and other major arteries ______________________ Pressure – the pressure that remains when the heart is resting between contractions. _______________________(MAP) - average pressure through the cardiac cycle and best indicator of organ perfusion under anesthesia = diastolic pressure + (systolic-diastolic pressures) 3 BLOOD PRESSURE Pulse pressure – pressure detected by manual palpation ◦ the difference between systolic and diastolic pressure Blood pressure can vary with age, breed, species, and instrumentation It is important to monitor TRENDS in blood pressure in addition to actual values BLOOD PRESSURE Normal systolic BP in awake dogs and cats:120 ◦ Normal range: 90-150 mm Hg ◦ Should ideally remain at or above _______mm Hg in anesthetized patients Normal diastolic BP in awake dogs and cats: 80 ◦ Normal range: 50-90 mm Hg Normal MAP: 90-100 mm Hg ◦ Should be maintained above ________mm Hg in anesthetized patients ◦ This is the best indicator of blood perfusion to the internal organs INDIRECT BP MONITORING ◦ Method most commonly used in private practice ◦ Noninvasive, less technically difficult than direct monitoring 2 types of INDIRECT BP monitors: ______________________ Measures systolic, diastolic, MAP _____________________ Measures systolic only INDIRECT BP MONITOR: OSCILLOMETRIC determines, systolic, diastolic, and MAP by detecting the oscillations within the cuff caused by the pulsation of the artery beneath the cuff Less labor intensive than Doppler monitors but tend to be less consistent in their ability to register blood pressures for smaller patients The machine can be set to automatically take a BP measurement every 2 to 3 minutes -1 minute cycles tend to create an ischemic challenge to the extremity Cuff width should be _______________of limb circumference for dogs and cats Excessively ___________cuffs will lead to an underestimation of blood pressure Excessively ___________ cuffs will lead to an overestimation of blood pressure Location of cuff is important Most consistent cuff location for small patients is the ________________, other: tail base, distal tibia Don’t hesitate to try all locations as needed Good locations for larger animals include metacarpus, metatarsus, and distal tibia just above tarsus - More consistently effective when monitoring small patients -Measures systolic pressure only -Hair is clipped at the probe site -The depression in the probe must be filled with ultrasound gel -place the probe over the metacarpal or metatarsal artery -Once you hear the swishing sound of the heart beat, tape the probe in place -Both excessive and inadequate pressure can create difficulties measuring accurately ◦ Cuff width is as important with doppler BP measurement as with oscillometric BP measurement Cuff width should be 30-50% of limb circumference for dogs Excessively wide cuffs will lead to an underestimation of blood pressure Excessively narrow cuffs will lead to an overestimation of blood pressure ◦5 readings are taken, the highest and lowest are thrown out. The average of the other 3 are used to determine the SAP. http://www.youtube.com/wa tch?v=Li4oGhfKmDQ http://www.vasg.or g/doppler_use.htm Used less than indirect methods in private practice ◦ Indwelling catheter is placed in ___________ or ______________________artery ◦ Catheter is connected to a manometer or pressure transducer via a fluid-filled tubing and the pressure is displayed http://www.vasg.org/direct_arterial_pressures.htm ◦ Check the patient! ◦ _______________________ the inhalant anesthetic setting ◦ ____________________the IV fluid flow rate ◦ ____________________ to ensure proper placement/size ◦ Finally…. Hetastarch, Dopamine, Dobutamine ….to be used in emergencies! Measurement of the blood pressure in a central vein: ______________________ Assesses how well the blood is returning to the heart and the ability of the heart to receive and pump blood ◦ Helpful in monitoring animals with right sided heart failure and preventing over-hydration in animals receiving IV fluids www.dcavm.org/08techmar.html http://books.google.com/books?id=LtGS0t1MI skC&pg=PA410&lpg=PA410&dq=manometer +veterinary+medicine&source=web&ots=BIO CQL_14Z&sig=MZnEtUSN6vpdi4TTnNjYkAduv a4&hl=en&sa=X&oi=book_result&resnum=9 &ct=result#PPA410,M1 Refers to measurement of ____________ by measuring dissolved oxygen and carbon dioxide gas in arterial blood. Indicate how well the patient is obtaining oxygen and delivering it to the tissues and how well the lungs are expelling carbon dioxide ◦ All of these depend on the respiratory function of the patient. OXYGEN EXISTS IN 2 FORMS IN THE BLOOD: 1) Free molecule dissolved in plasma (PO2 or PaO2) Measured by a blood gas analyzer Values below 60 mm Hg indicate hypoxia!! 2) Chemically combined with hemoglobin in RBCs (SO2 or SpO2) Measured by a _____________________ Not commonly used in private practice Blood sample should be taken from an artery Sample is placed on ice and should be run within 2 hours of collection Inexpensive, noninvasive, portable, easy to use Clip is placed on a thin strip of tissue that is nonpigmented and hairless ◦ Most commonly the _____________, but can also use the pinna, rectal mucosa, toe webbing, lip, vulvar fold, Achilles tendon, under base of tail Values should read _________% or greater under anesthesia ◦ Values between _______________% indicate hypoxemia ◦ Values less than 90% indicate a need for therapy Treatment: assisted ventilation, supplement oxygen ◦ Values less than ______% for greater than 30 sec. is a medical emergency PaCO2 : The portion of carbon dioxide that is dissolved in plasma (Carbon dioxide partial pressure in the arteries) ◦ Measured using a blood gas analyzer ◦ An awake patient’s levels are usually less than 45 mm Hg. It is common to see levels of ____________mm Hg in an anesthetized patient because the animal doesn’t breathe deeply enough to eliminate the usual amount of CO2 ◦ If greater than 60 mm Hg, hypoventilation is present. Assess other parameters to determine oxygenation and assist ventilation if necessary Carbon dioxide build-up can result in respiratory __________________ ◦ Commonly seen levels are 7.2-7.3 as compared to normal values of 7.35-7.45 ◦ Blood pH is measured via blood gas analyzers A ___________________ is placed on the endotracheal tube: it monitors the amount of CO2 that is expired Noninvasive ◦ Info is displayed as a graph Measures ______________________ As inspiration occurs, CO2 should be around __________ Hypercapnea: ET CO2 greater than ________mm Hg ◦ Causes: CO2 canister needs changing, hypoventilation (should correct when patient is bagged) Hypocapnea = ET CO2 less than 35 mm Hg ◦ Tachypnea, dead space, too much assisted ventilation, improper endotracheal tube placement/connection ◦ The main reason for a low SpO2 in an anesthetized patient is decreased ventilation 1) The animal is not breathing well and you need to assist it Respiratory rate should be 8 – 20 breaths /min for the average patient (avg = 10-12 bpm). Small patient may need more breaths. Try just occasional breaths at first 2) The patient has _________________________– the oxygen isn’t getting to the areas in the lungs where the blood is Check that the machine is hooked up properly Check that the oxygen is turned on/in tank Check that the endotracheal tube is placed correctly and the cuff is properly inflated. If the tube is in too far, the gas/O2 will only go to one side of the lungs. 3) The patient’s pulse is weak Check that the patient isn’t too deep Check the blood pressure and act accordingly (see section on blood pressure) 4) The sensor is slipping off the patient 5) The sensor has been at one location for a long time and is too dry or is pinching off blood supply to the area. The following locations may be used for the pulse ox. probe: tongue, lips, ear, toe webbing, prepuce, and vulva.
