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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 Image courtesy of profilethai.com • 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 Screensaver image courtesy of 8screensaver.com • Atropine /Glycopyrrolate –Heart rate increase –Decrease secretions –Parasympatholytic –Anticholinergic • Difference glycopyrrolate and atropine? Screensaver image courtesy of 8screensaver.com • 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 Screensaver image courtesy of 8screensaver.com • 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 Screensaver image courtesy of 8screensaver.com 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 Screensaver image courtesy of scenicreflections.com Wallpaper image courtesy of Computer Wallpapers at: http://www.freecomputerwallpapers.net/view/guard_cat_wallpaper-1600x1200.html 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 Wallpaper image courtesy of Lord Channel and WallPaper4God.com at: http://wallpaper4god.com/en/background_cat/ Cautionary Tale Most Dangerous Periods During Anesthesia? Induction Recovery “Dark Cat” wallpaper image courtesy of AnimalWallpapers.net AT: http://www.animalwallpapers.net/wallpaper/Dark-Cat/ Anesthesia monitoring • Parameter times? • 1st route of parameter correction • Time required to change anesthetic depth Image courtesy of http://nature-desktop.blogspot.com 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 Wallpaper image courtesy of ScenicReflections.com at: http://www.scenicreflections.com/download/278007/BLACK_CAT_Wallpaper/ t Anesthesia Monitoring Temperature • Affects everything else •Is affected by everything else •Is all too often ignored Wallpaper image courtesy of ScenicReflections.com at: http://www.scenicreflections.com/download/278007/BLACK_CAT_Wallpaper/ t Anesthesia Monitoring Blood Pressure • A must in small patients and cats •>60 mm Hg MAP •A dry kidney is a dead kidney •Lasting effects Wallpaper image courtesy of ScenicReflections.com at: http://www.scenicreflections.com/download/278007/BLACK_CAT_Wallpaper/ t Anesthesia Monitoring Pulse Oximetry • Gets the most love •Deserves it least Wallpaper image courtesy of ScenicReflections.com at: http://www.scenicreflections.com/download/278007/BLACK_CAT_Wallpaper/ t 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 Free screensaver image available at scenicreflections.com Ketamine • • • • • Pain Killer Used alone elevates BP (stimulates circulatory) Antidepressant Agitation and confusion Given IV/IM • NMDA receptor antagonist or classified as dissociative Free screensaver image available at scenicreflections.com 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 Free screensaver image available at scenicreflections.com Propofol • Given IV • Hypnotic/amnestic • • • • • • 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 Free screensaver image available at scenicreflections.com Alfaxan • Given IV for induction/IM for sedation • • • • • • Rapid onset of action Rapid elimination No extra-vascular tissue irritation Consecutive days use is fine Less respiratory depression Not analgesic Free screensaver image available at scenicreflections.com Isoflurane • • • • • • Halogenated Ether Inhalation anesthetic Mechanism of action is not understood Analgesic Muscle relaxant Potent vasodilator Free screensaver image available at scenicreflections.com 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 Free screensaver image courtesy of stockpile .com Reversible Sedatives Xylazine -Rompun -synthetic α2-adrenoreceptor agonist -makes cats vomit -reversed with yohimbine -sedative -analgesia Free screensaver image courtesy of stockpile .com