1/25/2010

INTRODUCTIONTO VETERINARYANAESTHESIA
ChrisSeymour
LecturerinVeterinary Anaesthesia,RVC

AIMSOFTHEANAESTHESIACOURSE
Toenableyoutoadministerasafeanaesthetic andprovide suitableperioperative analgesiatothedomesticspeciesandfor thesurgeryyouarelikelytomeetingeneralpractice
RCVSDayOneSkills:ParaC1.13Safelyperformsedation, generalandregionalanaesthesia,implementchemicalmethods ofrestraint,andassessandcontrolpain Tohaveanunderstandingoftheanaesthetic requirementsfor theotherspeciesorforadvancedsurgeryandwheretogofor help

REASONSFORANAESTHESIA
Restraint(includingcaptureofwild animals) Surgeryandpreventionofpain Diagnosticprocedures Diagnostic procedures Therapy Legalrequirements TheProtectionofAnimals (Anaesthetics)Act1964 TheAnimals(Scientific Procedures)Act1986 (MisuseofDrugsAct1971)

DEFINITIONS
Anaesthesia isalossofsensationcausedbypharmacological depressionofnervefunction Generalanaesthesiais astate ofunconsciousnessproducedby controlledreversible druginducedintoxicationofthe CNSinwhichthepatientneither PERCEIVESnorRECALLS noxiousstimuli

Localanaesthesiaisatemporaryblockadeofsensorynerves (usuallywithsimultaneousblockofmotornerves)

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GENERALANAESTHESIA
Sometimesdescribedas:

AIMSOFANAESTHESIA
Unconsciousness g ( p ) Analgesia(antinociception) Musclerelaxation Homeostasis Normaloxygendelivery

ReversibleDeath

GENERALANAESTHESIA THETRIAD

BALANCEDANAESTHESIA
Intheearlydaysonedrugwas used toprovideunconsciousness, analgesiaandmusclerelaxation g (e.g.diethylether)

NARCOSIS(UNCONSCIOUSNESS)

ANALGESIA (ANTINOCICEPTION)

MUSCLE RELAXATION

Balancedanaesthesiaistheuse ofsmallerdosesofseveraldrugs, eachhavingaspecificaction

PROCESSOFANAESTHESIA
Preanaesthetic assessmentandpreparation
Animalhistory Physicalexamination Preanaesthetic ancillarytests blood,Xrays,ECGetc.

PREOPERATIVEPREPARATION
Preanaestheticexamination
o Improvementofmedicalstate:choiceofanaesthetic

Starvation
o Speciesspecific

Evaluationofriskandformulationofanaesthetic plan
Premedication(includingthoughtsonperioperative analgesia) Inductionofanaesthesia Maintenanceofanaesthesia Recovery

Miscellaneous
o Clipping,cleanmouthandantitetanus,antibiotic,etc

Premedication
o Sedatives/analgesics,etc

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PREANAESTHETICASSESSMENT

BLOODTESTS
Detectionofsubclinicaldiseasewhichmayinfluence anaestheticmanagement Do they make a difference? Dotheymakeadifference? Indications
Signalmentofanimal History Proposedsurgery baselinevalues

History Physicalexamination Conductanytestsindicated Resultsofanytests available beforeanaesthesia Formulateperioperativeplan

Hb Neonates <12 w.o Geriatrics >8 y.o CV disease Resp disease PU/PD

PT/APTT

PLT

Elect BUN/ Gluc Creat

Liver TP/Alb Xray enzymes

ECG

Blood pressure

ANAEMIA
Lowhaemoglobin/packedcellvolume Decreasedoxygendeliverytotissues

(echo)

(if arrhythmia)

Renal disease Hepatic disease Clotting disorder Diabetes On diuretics On steroids

o OxygenDelivery=C.O OxygenContent o OxygenContent=(1.36 [Hb] SaO2)+(PO2 0.003)

Dependingoncondition,transfusiontriggerof 58g/dl[Hb]orPCV20%

HYPOPROTEINAEMIA
Changesinplasmaalbuminconcentrationchanges amountoffree/bounddrugconcentrations Plasma proteins maintain circulating oncotic Plasmaproteinsmaintaincirculatingoncotic pressure Riskofoedemaifalbumin<20g/l Plasmatransfusion,delayandfeed,human albumin

AZOTAEMIA
Bloodurea>10mmol/l,creatinine>200mmol/l Renalfailure,highproteindiet,dehydration Concurrentacidosisincreasesfreedrug concentrations,changesrestingmembrane potential,HbO2 dissociationcurve Diuresewithintravenousfluids,maintainBP

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ELECTROLYTES
Sodium<140>154mmol/l
o Controlfluidmovements o Cerebralfunction o Correctslowlywithhighorlowsodiumfluids

PREMEDICATION/INDUCTION

Potassium<3.5>5mmol/l
o Affectsexcitabletissue(nopotnot) o Bradycardia,arrhythmias,contractility o Supplementiflow;glucose/insulinifhigh(Calciumin emergency)

ENDOTRACHEALINTUBATION

MAINTENANCEOFANAESTHESIA

DEPTHOFANAESTHESIA

Inhalation TIVA Monitoring

Aim deepenoughtopreventmovementandawareness lightenoughsopreventlastingdamage Renal CNS Balancedanaesthesia

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MEASURINGTHEDEPTH(ADEQUACY)OF ANAESTHESIA
Speciesdifferencesinsignsofdepth Classicalconceptoriginallydescribedforethernow outdated:
STAGE1:Voluntaryexcitement STAGE2: Involuntaryexcitement STAGE3:Surgicalanaesthesia o Plane1:Light,briskreflexes o Plane2:Medium(surgicallevel) o Plane3:Deep,overdose! STAGE4: Dead

MEASURINGTHEDEPTH(ADEQUACY)OF ANAESTHESIA

Cardiovascular responsesto stimulatione.g.heart g rate,bloodpressure Respiratorychanges e.grateandtidal volume

MEASURINGTHEDEPTH(ADEQUACY)OF ANAESTHESIA

MEASURINGTHEDEPTH(ADEQUACY)OF ANAESTHESIA

Eyeposition,presence ofnystagmus of n stagm s (dependspartlyon drugsused) Lacrimation Pupilsizeandresponse tolight

Neurologicalresponses e.gcranialnerve reflexesandother reflexes

MEASURINGTHEADEQUACY(DEPTH)OF ANAESTHESIA

Musclerelaxation(jaw tone,neckmuscles) EEGchanges

From:BSAVAManualofCanineandFelineAnaesthesiaandAnalgesia(2nd Edition)

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SIDEEFFECTSOFANAESTHESIA

ANAESTHETICRISK:MORTALITY
Generalanaesthesiaalwayscarriessomerisk

Cardiovascularandrespiratorydepression Obtundedhomeostaticmechanisms e.g.baroreceptorreflex,pulmonaryhypoxicresponse Specificdrugeffects e.gNSAIDsandrenalfunction

CEPSAF HealthyDogs HealthyCats Healthy Cats Rabbits CEPEF Horses

1in1850 1in900 1 in 900 1in72 1in100(worseifcoliccasesincluded)

(Humansapprox.1in10000overall)

ANAESTHETICRISK:MORBIDITY
Pathologyresultingfromanaesthesia notresultinginimmediate death(orwithin7days) Failureofanimaltoreturntopreoperativestate Examples Muscledamage Nervedamage Cerebralhypoxia(blindness), memoryloss Renaldysfunction Pulmonarydysfunction

WHATAFFECTSRISK?

Conditionofanimal(includingtemperament) Experienceofstaffinvolved(includesvetandnurse) Facilitiesavailable Choiceoftechnique

INANAESTHESIAITIS
Themosteffective monitorsaretheeyes andearsofatrained humanbeing.However, g , tobeeffective,justlike amachine,theymust beturnedon

THEINDIVIDUALTHAT MATTERS!!

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ASSESSMENTOFRISK
ASACLASS

ASASYSTEM
PHYSICALCONDITION Normalhealthyanimal,no underlyingdisease Mildsystemicdisturbance butnoclinicalsigns Moderatesystemic disturbancewithmild clinicalsigns Severesystemicdisturbance thatisaconstantthreatto life EXAMPLES Electiveneutering,HD radiography Obesity,uncomplicated fracture,milddiabetes, y p asymptomaticheartdisease Symptomaticheartdisease, anaemia,moderate dehydration,pyrexia Severeheartfailure,sepsis, uraemia I II

Physicalstatusscorecanbeassignedtoanimalafter examination BasedonAmericanSocietyofAnesthesiologists (ASA)scalefor Based on American Society of Anesthesiologists (ASA) scale for humans Identifiesanimalsthatneedspecialattention REMEMBER:Overallriskaffectedbyphysicalstateofanimal plus otherthings

III

IV

Moribundanimalnot Shock,severetrauma,GDV expectedtosurvive24hours withouttreatment

ADDETONUMBERIFPROCEDUREISANEMERGENCY

HOWCANWEREDUCERISK?
Examinepatient(includeshistory) Preparepatientproperly!!!!!(mayincludefurthertests) Checkallanaestheticequipmentbeforeuse Appropriateuseofdrugs Constantmonitoring(keepanaestheticrecord) Intraoperativesupport(fluids,keepwarm,drugs) Propercareinpostopperiod(manyanimalsdieinrecovery)

WASTEANAESTHETICGASES

Whyworry? Nodefinitiveevidencethatexposuretotraceamountsis harmful Suspectedadverseeffects cancer,miscarriage,liverand kidneydamage,immunosuppression,psychological disturbance

WASTEANAESTHETICGASES
Nitrousoxideprobablymoredangerous: InhibitsDNAsynthesis Cancausemegaloblastic changes inbonemarrow Chronicexposurecancausespinalcord degeneration

HOWCANWEMINIMISEEXPOSURE?
Usescavengingsystems(AGSS) properly Serviceallanaestheticmachines andvaporizersregularly Avoidmaskorchamberinduction ofanaesthesia Inflateendotracheal tubecuffproperly (preferablybeforeturningvaporizeron!)

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JUGINDUCTION!

HOWCANWEMINIMISEEXPOSURE?
Fillvaporizersatendofdayifpossible withkeyfillersorQuickFillsystem Capemptybottlesofanaesthetic beforediscarding Leavepatientsattachedtocircuitas longaspossible,withETTcuffinflated

WASTEANAESTHETICGASESAND PREGNANCY
Increasedrateofabortioninfemaleanaesthetistscompared withfemalephysiciansworkingoutsideoperatingareas(pre scavengingdays) Increasedincidenceofcongenitalabnormalitiesinchildrenof bothmaleandfemaleanaesthetists Couldbeduetootherreasons:stress,radiation,contactwith otherorganicchemicals

WASTEANAESTHETICGASESAND PREGNANCY
Commonscenarioingeneralpractice Avoid(orminimise)exposure: Usescavengingsystemsproperly! Use scavenging systems properly! Dontusenitrousoxide Improveventilation Pregnantstaffdonotfillvaporizers Keepawayfromrecoveryareas(oftenthemostpolluted) Leaveanimalsconnectedtocircuitaslongaspossible PregnancyinPracticedocumentonRCVSwebsite

WASTEANAESTHETICGASESAND PREGNANCY
Specialfacemasks (butuncomfortable likeagasmask!) Assigndutiesawayfrom operatingareas Monitorenvironmental levelsregularly (every612months)

WASTEANAESTHETICGASES: EXPOSURELIMITS
ContainedintheControlofSubstancesHazardoustoHealth (COSHH)Regulations allpracticesmustcomply FortheUK: Nitrousoxide Isoflurane Sevoflurane Halothane

100ppm 50ppm 60ppm 10ppm

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MONITORINGINTHEWORKPLACE

TOPICSFORTHISCOURSE

Shouldbedoneevery612months CheaperservicerunthroughBSAVA Ch i h h BSAVA AnaestheticMonitoringScheme (www.bsava.com) Allpracticesmustcomply (HSEwillbewatching)

Apparatustoadministeranaestheticagents Painandanalgesia Pain and analgesia Sedation Inductionofanaesthesia Maintenanceofanaesthesia Monitoringandcareoftheunconsciousorsedated patient

TOPICSFORTHISCOURSE

Localanaesthesia Equineanaesthesia Equine anaesthesia Speciesdifferences AnaestheticAccidentsandEmergencies