SMALL ANIMAL ANESTHESIA

2012.04.10.

SMALL ANIMAL ANESTHESIA

Nationale

Species, breed, sex, age, bwkg (bsa m2 = 0.1 x bwkg2/3)

ANESTHESIA 3.1 3.1--3.3 2012

Dr. Miklós Pál Dunay Szent István University, Faculty of Veterinary Science Department and Clinic of Surgery and Oph Ophthalmology

Anamnesis

Anamnesis – Symptoms, origin of complaint, duration, treatment – Previous illness, known changes, drug sensitivity, allergies

Status praesens

Emergency „ABC” patient examination

Recommended examination

– Airway patency, breathing, circulation, CNS – Heart, Heart, circulation, breathing, CNS, liver, liver, kidney, body temperature temperature

Detailed patient exam. exam. (phys. and acc.) – Skin, lymph nodes, muco mucous membr., membr., respiratory org. org., circulation, GI syst., syst., urinary org. org., genital org. org., blood gen. gen. org. org., endocrine syst., syst., locomotor org org.., CNS

Thoracic Thora cic X-ray

Thoracic Thora cic X-ray

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Cardiology (US, ECG)

Blood sampling for laboratory analysis

Laboratory analysis

Blood gas analysis

CEPOD, ASA classification classification

Surgical consent

CEPOD (I (I--IV) urgency classification ASA (1 (1--5, E) risk classification

„Every anesthesia and surgery has a risk! As the undersigned pet owner I declare that I was informed of the circumstances, risks, and d possible ibl consequences off the th above b procedure, and that I understand them and accept them. I agree to allow the surgery and will perform subsequent atat-home care according to the surgeon’s surgeon’s instructions.” instructions.”

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SZENT ISTVÁN EGYETEM ÁLLATORVOS-TUDOMÁNYI KAR SEBÉSZETI ÉS SZEMÉSZETI TANSZÉK ÉS KLINIKA KISÁLLATSEBÉSZETI MŰTŐBLOKKOK ANESZTÉZIA-PROTOKOLL

SZENT ISTVÁN EGYETEM ÁLLATORVOS-TUDOMÁNYI KAR SEBÉSZETI ÉS SZEMÉSZETI TANSZÉK ÉS KLINIKA H-1078 Budapest, István u. 2. Tel.: (06 1) 478 41 97 Fax: (06 1) 478 41 96 www.univet.hu [email protected]

Rendelési idő Sebészet: hétköznap 9-15.30 Szemészet: hétfő 9-12, csütörtök 15-17.30 Fogászat: telefonos egyeztetés alapján Sürgősségi ügyelet: minden nap 0-24

Dátum:

Beavatkozás:

Sebész:

Asszisztens:

Állat faja:

fajtája:

Preparation

Törzsszám:

Altató orvos:

kora:

ivara:

tömege (kg):

Keringés:

Légzés:

Hőmérséklet

Laborértékek:

Szívritmus Pulzus (1/perc) Nyálkahártyák színe CRT (sec) Bőrturgor

L.minta L.szám (1/perc)

Rektális (ºC)

Ht 3 TPP (g/dl ) ALT (NE/l) UREA (mmol/l) CREA (μmol/l)

ASA:

MŰTÉTI ELŐJEGYZÉS / FONTOS TUDNIVALÓK • • • • • • • • • •

Altatás előtt 12 órán át koplaltassa az állatot! Az állat korábbi betegségeiről, műtéteiről, gyógyszerérzékenységről tájékoztassa az állatorvost! Az állatot altatás után a teljes felébredésig tartsa zárt helyiségben, szobahőmérsékleten! A félrenyelés veszélye miatt ne etesse, ne itassa, amíg teljesen magához nem tér! Az ébredési idő függ a fajtától, az életkortól, az általános állapottól, stb. Az ébredés átmeneti izgalommal, nyálzással, nyüszítéssel, remegéssel járhat. A műtétet követő egy-két napban bágyadtság, étvágytalanság jelentkezhet. Varratszedésig gondoskodjon a seb védelméről (műanyag gallér, stb)! Az állat utólagos otthoni ápolását, diétás etetését az állatorvos utasításai szerint végezze! Ha váratlan tünet lépne fel (jelentős vérzés, helyi duzzanat, láz, rosszullét, stb), kérjük jelentkezzen kezelőorvosánál!

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Premedikáció:

Indukció:

(szer neve, adagja, beadás módja, időpontja)


Intraoperatív gyógyszerek:

Posztoperatív gyógyszerek:



MŰTÉTI ELŐJEGYZÉS / NYILATKOZAT Tulajdonos

név:

………………………………………

cím:

………………………………………………………………………………………………

Állat

törzsszám: faj:

kutya

macska

egyéb:

…....………..

temperamentum: barátságos, félénk, agresszív korábbi műtétek (gastropexia, daganat, stb)

tel.:

ASA:

1 (6hét-5év)

2 (-6hét,5év-)

ivar: ♂ ♀ (vemhes)

…...............

fajta:

…...........................…………………

koplaltatás:

igen nem

………………………………………………. ………………………………….……………

3 (-3nap,8év-)

Patient

Medication

– Fasting, Fasting, stabilization stabilization,, antibio antibiotics tics,, analgetics

...........................................................

kor:

fennálló betegségek (szív, epilepszia, endokrin, stb) ………………………….………..………….. gyógyszerek, gyógyszerérzékenység, allergia

4 (-3nap,10év-)

5

V

O2 (l/perc) Halo/ Iso/ Sevo (V%) SpO2 (%) Pulzus (1/perc) etCO2 (mmHg) Nyálkahártyák Színe

Diagnózis / beavatkozás ………...........................…………………………………………………………………… Minden altatás és műtét kockázattal jár! Alulírott állattulajdonos (megbízott) kijelentem, hogy a fent nevezett beavatkozás körülményeiről, kockázatáról és esetleges szövődményeiről tájékoztatást kaptam, azokat tudomásul vettem és elfogadom. A beavatkozáshoz hozzájárulok, a beteg otthoni ápolását az utasítások alapján végzem.

– Anesthetics, Anesthetics, emergency drugs drugs,, other other drugs

Időpont Incisio I Műtét vége - V Ébredés - É

CRT (sec)

Equipment – Anesthesia machine and/ and/or or infusion pumps pumps,, monitoring equipment

Műtét leírása / Folyadékterápia / Megjegyzések, észrevételek:

Budapest 2006. ..................

......................................................... állatorvos

........................................................... tulajdonos (megbízott)

Filling the a absorbe bsorbent nt canister

Check the vaporiser

Filling the vaporizer

Check O2 supply and regulator

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Assembly of semi semi--closed and closed circuit

Pressure test of semi semi-closed and closed circuit

Assembly of semi semi--open system

Setting the temperature of the ssurgical urgical table

Warming pad with water circulation

Preparation of pulsoxypulsoxymeter and capnograph

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General anesthesia 1


Premedication

– Decreases stress, fear, aggression, and accidents – Decreases dose and side effects of further anesthetics anesthetics – Anesthesia is more balanced – Costs decrease – Sedation not required in bad general condition

G

Length (mm)

Diameter (mm)

Capacity (ml/min)

Yellow

24

19

0.4 x 0.7

18

Blue

22

25

0.6 x 0.9

36

Pink

20

33

0.7 x 1.1

61

Green

18

45

0.9 x 1.3

90

White

17

45

1.1 x 1.5

140

Grey

16

45

1.3 x 1.8

200

Orange

14

45

1.5 x 2.1

300

Danger of embolism! embolism!

– Ensure venous access – Establish an insensate state – Intubation

(Vasofix)

IV catheter (Vygonüle) Color Code

Induction

V. cephalica antebrachii, v. saphena

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Establishing venous access

Establishing venous access

Induction (propofol iv.)

Intratracheal tube

Selecting an intratracheal tube


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Kinking

Lumen will not decrease (metal spiral spiral))


Intubation of a dog

Intubation of a dog

Induction (propofol iv.) and intubation

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Laryngeal opening of the cat


Maintenance – Hypnosis (u (unconsciousness nconsciousness)), Analgesia g ((no p pain), pain ), Muscle relaxation (no movement) movement) – Inhalation and/ and/or or injection (TIVA)

Setting O2 flow

Connecting the patient patient to semi semi--closed circuit

Setting V% of an inhalation anesthetic

General infusion therapy

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Analgesia (ketamine + fentanyl inf.)

Intercostal block (lidocaine + bupivacaine)

Pulseoxymetry, Pulseoxymetry, capnometry

Perioperative monitoring

Monitoring – Heart function, circulat circulation ion – Breathing – Body ttemperature emperature – Consciousness – Pain ain--markers – Etc.

Pulseoxymetry

Pulseoxymetry

Capnometry

– SpO2: 9898-100% – etCO2 (<paCO2): 3535-45 mmHg (mmHg = 0.133 kPa; kPa = 7.5 mmHg)

Pulseoxymetry

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Capnometry

Esophageal stethoscope

Doppler BP monitoring

Fluid homeostasis, BP maintenance

During spont. respiration: overpressure valve open

During assist. respiration espiration:: overpressure valve closed

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Ventilation (ie. open chest)

Visual respiratory check

End of the maint. phase: phase: V% decrease

General Anesthesia 4

Waking – Anesthetic uptake ceases (passive) – Metabolism and elimination

Wakening – Antagonization (active) (benzodiazepines (b enzodiazepines,, alfa2-agonists, opioids opioids,, nondepolarizing muscle relaxants relaxants))

Recovery, extubation extubation

Anesthetics & other drugs 1

Anticholinergicss (atropine, glucopyrrolate) Anticholinergic Phenothiazine derivatives (ACP) Benzodiazepines (diazepam, (diazepam midazolam) Alfa2-agonists (xylazine, medetomidine) Opioids (butorphanol, fentanyl) NSAIDs (carprofen, meloxicam)

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Barbiturates (thiopental) IV hypnotics (propofol) Steroid anest. anest. (alfaxalone/alfadolone) (alfaxalone/alfadolone) Dissociative anest anest.. (ketamine, tiletamine)

Recommended preoperative analgesia 1

Opioids – Fentanyl (0. (0.001 001--)- 0.02 mg/ mg/bwkg bwkg iv., then ((0. (0.0012 0012--) 0. 0.02 mg/ mg/bwkg g/bwkg/ g/h iv. – Butorphanol 0.1-0.3 mg/ mg/bwkg bwkg im., im., iv.



Neuroleptanalgesia (NLA)

Ataranalgesia

– Opioid (fentanyl) fentanyl) + tranquilizer (ACP) – Opioid (fentanyl) fentanyl) + benzodiazepine (midazolam) midazolam) – For dogs dogs: midazolam 0.5 mg/bwkg mg/bwkg im., im., iv. And fentanyl 0.02 mg/ mg/bwkg bwkg im., im., iv.

or nalbuphine 0.5-1 mg/bwkg mg/bwkg im., im., iv. – Buprenorphine 0.01 01--0.04 mg/ mg/bwkg bwkg im., im., iv.


Alpha2-agonists

– 1-2 µg/bwkg µg/bwkg medetomidine iv.

NMDA antagonists g – Ketamine 0.25 25--0.5 mg/ mg/bwkg bwkg iv. (tiletamine (tiletamine))

NSAID’’s NSAID – Generally: enerally: COX inhibition, kidney perfusion maintained by PG’s, PG’s, insuff insuff.., kidney failure – Carprofen 2.2 mg/bwkg mg/bwkg iv. (dog) – Meloxicam 0.2 mg/bwkg mg/bwkg iv. (dog)

Inhalational anesthetics (halothane, isoflurane,, sevoflurane isoflurane sevoflurane,, N2O) Local anest anest.. (lidocaine lidocaine,, bupivacaine bupivacaine)) Muscle relaxants (pancuronium (pancuronium,, atracurium,, vecuronium atracurium vecuronium,, rocuronium rocuronium))


Localanesthesia (LA): superficial and freezing – Injured skin or muc muco ous membranes – Opht phth halmology – Intubation – „Freezing „Freezing”” anesthesia

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LA: infiltration


– Thoracotomy, rib fractures – Cran. ran and caud. caud 11-3 rib spaces from wound – Nerves are on caudal border of rib – Drug administration as dorsal as possible – Lidocaine 1. 1.5 mg/bwkg + bupivacaine 1. 1.5 mg/bwkg

– Safest LA technique – 0.5-2% lidocaine – 0.3-0.5 ml/cm depots along the incision line – Effect after ccca ca.. 15 min, for 30 min – With epinephrine (vasoconstriction): may lead to local ischemia and necrosis


LA: intraarticular intraarticular application


– Bup upiivacaine 0. 0.5% (1 (1--6 ml, dep. dep. on size); dog g max. 1 mg/bwkg; g/ g; cat max. 0. 0.5 mg/bwkg; effect after 55-10 min for 44-8 h – Lidocaine dog max. 4 mg/bwkg; cat max. 1 mg/bwkg effect after 55-10 min for 11-2 h

Recomm. preop. analg nalg.. 9 LS EDA (L7 (L7--S1) bolus

Lidocaine 2% 1 ml/5 bwkg (max. 20 ml)

EDA + superficial general anesthesia – Cesarean section, shock patient, etc.

Recomm. preop. analg nalg.. 10 LS EDA (L7 (L7--S1) bolus

Medetomidine

– Cesarean section i

Fentanyl

– 2-3 h

– Analgesia caudal to diaphragm (1(1-2 h)

LA: intercostal block

Lidocaine 2% 1 ml/6 bwkg

Bupivacaine 0.5% 1 ml/5 bwkg

Lidocaine 1% 1 ml /15 cm

Overdose

– 0.01 01--0.015 mg/bwkg (1 (1--8 h) – 0.001 001--0.01 mg/bwkg (3 (3--5 h)

Other alpha2-agonists and opioids

– Refers to length of analgetic area – Respiratory paralysis, cardiovascular depr depr..

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Recommended intraop.. analgesia 11 intraop

Ketamine continu continuous infusion


– Lidocaine for dogs 1-2 mg/bwkg mg/bwkg iv. bolus induction prior i to t gen. anesthesia th i (5 min) i ) 10--50 µg/bwkg 10 µg/bwkg/min /min = 0. 0.6-3 mg/bwkg mg/bwkg/h /h iv. during maintenance – Lidocaine for cats 0.25 mg/ mg/bwkg bwkg iv. bolus 0.6 mg/ mg/bwkg bwkg/h /h iv. during maintenance – Fentanyl 1-5 µg/bwkg µg/bwkg iv., then then 1.2-4 µg/bwkg µg/bwkg/h /h

– NMDA antagonist – 0.25 25--0.5 mg/bwkg mg/bwkg initial dose – 0.12 12--1.2 mg/bwkg mg/bwkg/h /h maintenance dose


Ketamine + fentanyl contin continu uous inf.

Lidocaine + fentanyl contin continu uous inf. nf.

Recommended postop.. analgesia 14 postop

– 0.6 ml Ketamine 100 mg/ml A.U.V. inj. inj. (or 1.2 ml Ketamine 50 mg/ml human inj.) inj.) + 12 mll Fentanyl F t l 0.25 0 25 mg/5 /5 mll inj iinj. j. ad 500 ml. sterile Saline inf. inf. – Dogs 3 ml/ ml/bwkg bwkg/h /h ((cats cats 1 ml/ ml/bwkg bwkg/h) /h) iv. iv.

Fentanyl patch – Only permitted in clinics (addictive drug!) bwkg: 25 µg/h, µg/h, – 2.52.5-5 bwkg: bwkg: 12.5 µg/h µg/h,, 5-10 bwkg: 10--20 bwkg: 10 bwkg: 50 μg μg//h, 2020-30 bwkg: bwkg: 75 µg/h, µg/h, > 30 bwkg: bwkg: 100 µg/h µg/h – In dogs onset: onset: 12 12--24 h, steady state: state: 3 days – In cats onset onset:: 4-8 h, steady state: state: 5 days – May be placed 24 h prior to surgery

NSAID’’s NSAID – Postoperatively the labeled NSAID’s

General Protocols Premedication Premedi cation 1

ASA 11-2 premedication (butor. butor. ↔ fenta fenta.!) .!) – Fentanyl * – Acepromazine (Ca: 0.02 mg/bwkg mg/bwkg im im., ., Fe: 0.2 mg/bwkg mg/bwkg im.) im.) and butorphanol (0.1(0.1-0.4 mg/bwkg mg/bwkg im., im., iv.) – Medetomidine (0.01 (0.01--0.04 mg/bwkg mg/bwkg im.) im.) and butorphanol (0.1(0.1-0.4 mg/bw mg/bwkkg im., im., iv.) – Medetomidine (0.02 mg/ mg/bwkg bwkg iv.) and ketamine (1 mg/bwkg mg/bwkg iv.) and butorphanol (0.4 mg/bw mg/bwkkg iv.)

General Protocols Premedication Premedi cation 1

ASA 33-4 premedication (butor. butor. ↔ fenta fenta.!) .!) – Fentanyl* Fentanyl* – Midazolam (0.5 mg/bwkg mg/bwkg im im., ., iv.) and butorphanol (0.1(0.1-0.4 mg/bwkg mg/bwkg im., im., iv.) – Diazepam (0.5 mg/bwkg mg/bwkg iv.) and butorphanol (0.1(0.1-0.4 mg/bwkg mg/bwkg im., im., iv.)

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General Protocols Induction 1

ASA 11-2 induction

General Protocols Induction 2

– Ketamine (10 mg/ mg/bwkg bwkg iv.) and diazepam p ((0.5 mg/bwkg mg/ g/bwkg g iv.))

Note – Ultrashort acting barbiturates barbiturates,, steroid anesthetics (and inhalational anesthetics) anesthetics) are also useful for induction

ASA 1-4 induction – Propofol (1 (1--5 mg/bwkg mg/bwkg iv. to effect)

General Protocols Maintena Mainten ance 1

Inhalational maintenance

General Protocols Maintenance 2

– Isoflurane, sevoflurane (2(2-3 V%, 2 MAC) (O2 33 33--100%,, 11-2 l/min) / )

General Protocols Maintenance 3

Note – Induction drugs may be used for maintenance,, dosed for effect (not including barbiturates and benzodiazep benzodiaze pines in combination with ketamine)) ketamine

Total IV maintainance (TIVA) – Propofol (15 mg/kg/h, in Dextrose 5% inf.) fentanyl y (0.02 ( mg/kg/h g/ g/ iv.,, in RL inf.))

Emergencies 1 Antagonization

Benzodiazepines – Flumazenil (Anexate) 0.03 mg/bwkg iv. – Sarmazenil ((-)

Alpha2-agonist agonistss – Atipamezol (Antisedan) dose to effect im., iv. (max. agonist 5x dose) – Yohimbine (Yobine) – Tolazoline (Priscol) – 4-aminopiridine ((-)

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Opioidss Opioid


– Naloxone (Narcanti) to effect 0.0010.001-0.2 mg/bwkg g/ g iv. (duration: ( 11-3 h)) – Naltrexone (Nemexin) po. (duration: 11-2 days) – Nalmefen ((-)

Emergencies 4

Bradycardia

– AcChAcCh-esterase inhibitors (not registered!) – Neostigmine (Prostigmine) 0.04 mg/bwkg iv. (may repeat after 5 min: total dose max. 0.12 mg/bwkg iv.) – Pyridostigmine (Mestinone) – Edrophonium (Tensilon)

Emergencies 5

– Glycopyrrolate (0.01 mg/ mg/bwkg bwkg iv.) or atropine p ((0.02 mg/bwkg mg/ g/bwkg g iv.))

– Dobutamine (1 (1--5 μg/ g/bwkg bwkg iv.) or etilefrine (0.05 (0.05--0.1 mg/bwkg mg/bwkg iv.)

Ventricular fibrillation

Emergencies 7 CPR

Lung edema – Furosemid (2 (2--4 mg/bwkg iv.)

Eliminate anesthetic effects – Stop administration – Antagonization

Hypoventilation – Doxapram (1 (1--2 mg/bwkg iv.)

Detecting heart sstandstill tandstill – Note the time – Summon assistance (survivability ↑)

– Epinephrin (0.1 mg/bwkg iv., intratrach.)

Extrasystole – Lidocaine 1% (Dogs: ((Dogs g : 0.2 0.2--0.4 ml/bwkg / g iv.,, then drip p infusion. 5 ml ad 45 ml Ringer inf., 1.51.5-5 ml/bwkg/h iv. iv.)) (Cats:: 0.02 (Cats 0.02--0.07 ml/bwkg iv., then drip infusion 5 ml ad 45 ml Ringer inf., 0.60.6-2.4 ml/bwkg/h iv iv.) .)

Hypotension

Emergencies 6

Nondepolarizing muscle relaxants

Intubation, ventilation with with 100% O2 – 1010-15/min – 1010-15 cmH2O inspiratory pressure

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Emergencies 8 CPR

Continous Con tinous external heart massage

Emergencies 9 CPR

– Epinephrin 10 µg/bwkg iv., it. (0.1 ml/10 bwkg) – In case of no effect, after 2 min: + 5050-100 µg/bwkg (0.5(0.5-1 ml/10bwkg) then every 44-5 min + 1010-20 µg/bwkg (0.1--0.2 ml/10 (0.1 ml/10bwkg) bwkg) – Alternatively: epinephrin inf. 0.1 µg/bwkg/min + 0.02 mg/bwkg atropin iv.. it. – Alternatively: dopamin inf. 7 7--10 µg/bwkg/min

– 100/min

Vein catheterisation – Rapid fluid admin. (10(10-20 ml/bwkg RiRi-lac)

Pulse evaluation, perfusion correction – Epinephrine, Epinephrine, dopamine

Internal heart massage – Thoracotomy

Emergencies 10 CPR

ECG exam: fibrillation – Spontaneous defibrillation – Electronic defibrillation – Chemical defibrillation (AcChCl or AcCh 6 mg/bwkg iv. +K K--citrate or KCl 1 mg/bwkg iv.) iv.)

ECG exam: asystole

Emergencies 11 CPR

ECG exam: normal ECG without without pulse – Dopamin 77-10 µg/bwkg/min iv. – Atropine 0.020.02-0.04 mg/bwkg iv. (in case of bradycardia)

Emergencies 12 CPR

Return of heart function – Continue heart massage – Dopamine 5 µg/bwkg/min iv. – Blood gas analysis (if available) – (Methyl(Methyl-)prednisolone)prednisolone-Na Na--succinate 30 mg/bwkg iv. – Deferoxamine 30 mg/bwkg im. (avoid reperfusion syndrome) syndrome) – Correction of fluid homeostasis

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SMALL ANIMAL ANESTHESIA

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