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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 Advanced Medical Care: Improving Veterinary Anesthesia Thursday, April 23, 2009 By Tamara Grubb, DVM, MS, DACVA AAHA

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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 1

Advanced Medical Care: Improving Veterinary Anesthesia

Thursday, April 23, 2009 By Tamara Grubb, DVM, MS, DACVA

AAHA gratefully acknowledges the following for their sponsorship of this Web Conference:

Advanced Medical Care: Improving Veterinary Anesthesia

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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 2

 1989 Standard Patient

  • Young, healthy
  • Spay, castration

 2009 Standard Patient

  • ????
  • Advanced disease
  • Advanced age
  • Advanced surgical

procedures

 ADVANCED ANESTHESIA

 Anesthesia is an event, not a drug choice  The event should include

  • Appropriate patient preparation
  • Preemptive, multimodal analgesia
  • Balanced anesthesia
  • Support & MONITORING

▪ From pre-op to post-op – not just while in the OR ▪ Most unexpected anesthetic deaths occur in recovery

Preanesthesia Induction Maintenance Recovery

  • Achieve unconsciousness smoothly &

rapidly; dose TO EFFECT

  • Dose TO EFFECT; May need to add more

analgesia; MONITOR & SUPPORT

  • May need more analgesia and/or sedation
  • MONITOR & SUPPORT
  • Patient preparation for anesthesia
  • SEDATION & ANALGESIA
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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 3

 The administration of analgesic and sedative

drugs in the pre-operative period allows a decrease in the dosage of induction and maintenance anesthetic drugs

  • Side effects of anesthetic drugs

are DOSE DEPENDENT

 Decreased stress for the patient

  • Decreased release of catecholamines

 Decreased work for the staff

  • Calm patients are easier to work with

 Receptors in dorsal horn of spinal

cord become ‘upregulated’ or ‘hypersensitized’ from painful impulses

 Preemptive analgesia decreases

input to these receptors

 Multimodal drug delivery ‘blocks’

pain pathway at different sites

  • Effects of drugs are synergistic

From: Pain Management for the Small Animal Practitioner, Tranquilli, et al. Teton New Media

 Patients that received adequate analgesia:

  • experienced fewer complications

▪ GI dysfunction (indigestion, ileus, ulceration) ▪ Clotting dysfunction (hypercoaguability, emboli) ▪ Pulmonary dysfunction (atelectasis & pneumonia)

  • healed faster, better long term results

▪ Decreased cortisol release

References: Alder et al, Swiss Med Wkly 2004; Callesen, Dan Med Bull 2003; Cohen et al, Am J Phys Med Rehabil 2004.

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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 4

 Analgesics

  • Opioids
  • Alpha-2 agonists
  • NSAIDs

 Tranquilizers

  • Opioids
  • Alpha-2 agonists
  • Acepromazine
  • Benzodiazepines

 Most potent class of analgesic agents  Should be included ANYTIME that pain occurs,

especially when pain is moderate to severe

  • This includes surgical, medical and

traumatic pain whether acute or chronic

 MINIMAL SIDE EFFECTS – high safety margin

  • ‘Respiratory depression’ is over-rated
  • Minimal to no cardiovascular effects

 Relatively short acting when compared

to the duration of pain

  • Use multimodal analgesia
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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 5

 Morphine, hydromorphone, fentanyl

  • Most potent opioids due to receptor

binding

  • Moderate duration, moderate to good

sedation (depending on species, age, health)

  • INEXPENSIVE

 Buprenorphine

  • Moderately potent, longer duration of

analgesia, minimally sedating

 Butorphanol

  • Moderately potent, short duration
  • f action, excellent sedative

 Advantages

  • Provide analgesia and sedation
  • Reversible
  • Can titrate sedation from mild to

profound

 Disadvantages

  • Cardiovascular effects

▪ Hypertension, increased cardiac work

 Bradycardia is a normal reflex

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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 6

 Advantages

  • Inexpensive
  • Mild to moderate sedation
  • Long lasting

 Disadvantages

  • MAY contribute significantly to

hypotension, hypothermia

  • MAY last too long
  • No analgesia, not reversible

 Advantages

  • Minimal to no cardiovascular or

respiratory depression

 Disadvantages

  • Generally will not get good

sedation when used alone in young or aggressive patients

 Dose

  • 0.1-0.2 mg/kg

 Lipid soluble

  • Administered IV or
  • rally
  • Slightly less potent
  • Slightly longer

duration of action

 Water soluble

  • Can administer by

various routes ▪ IM, IV, intranasally, rectally, orally

  • Clinically very similar

to diazepam

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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 7

Preanesthesia Induction Maintenance Recovery

  • Achieve unconsciousness smoothly &

rapidly; dose TO EFFECT

  • Dose TO EFFECT; May need to add more

analgesia; MONITOR & SUPPORT

  • May need more analgesia and/or sedation
  • MONITOR & SUPPORT
  • Patient preparation for anesthesia
  • SEDATION & ANALGESIA

 Ketamine / valium  Propofol  Other choices

  • Telazol, thiobarbiturates,

etomidate

 USE THE RIGHT DOSE!  DOSE ‘TO EFFECT’.

 Advantages

  • Generally, no cardiovascular

depression

  • Minimal respiratory depression
  • Can administer IM

 Disadvantages

  • Must be combined with sedative
  • Can cause tremors, excitement,

muscle rigidity

  • Recoveries can be rough
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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 8

 Advantages

  • Fast acting

▪ EASY to dose to effect

  • Short duration
  • Good muscle relaxation
  • Cleared from body by

multiple routes

 Disadvantages

  • Moderate respiratory depression
  • Mild to moderate cardiovascular depression

 NOT recommended for most cases

  • Too slow, not controlled,

excitement common

  • High drug dosage
  • STAFF EXPOSURE

 DEFINITELY NOT for cases

in which excitement can be detrimental

  • Cardiovascular disease, upper airway

dysfunction, etc.

Preanesthesia Induction Maintenance Recovery

  • Achieve unconsciousness smoothly &

rapidly; dose TO EFFECT

  • Dose TO EFFECT; May need to add more

analgesia; MONITOR & SUPPORT

  • May need more analgesia and/or sedation
  • MONITOR & SUPPORT
  • Patient preparation for anesthesia
  • SEDATION & ANALGESIA
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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 9

 Advantages

  • Easy to change anesthetic depth
  • Minimal metabolism compared to

injectable agents

  • Protected airway, O2 administration

 Disadvantages

  • DOSE-DEPENDENT cardiovascular

and respiratory depression

  • Dose to effect

 Solubility

  • Virtually insoluble

▪ Blood-Gas Solubility ▪ Sevoflurane 0.69 ▪ Isoflurane 1.38

  • Low solubility provides extremely

rapid induction, change of anesthetic depth and recovery

 Can be everyday, sole inhalant  Any case benefitting from smooth,

rapid and ‘thorough’ recovery

▪ No dysphoria, No residual sedation

  • C-sections
  • Outpatient procedures
  • Neonates / geriatrics
  • Etc…
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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 10

 Inhalant anesthetics are biggest

contributors to:

  • Hypotension, hypoventilation, hypothermia
  • KEEP YOUR VAPORIZER SETTING LOW

 Best way to decrease vaporizer setting is

to increase analgesia

  • Local anesthetic blockade
  • Supplemental opioid or alpha-2 agonist doses
  • Constant rate infusions (CRIs)

 If you could have only ONE

monitor, what would it be?

  • A good technician!

 Anesthesia causes depression of ALL organ systems

  • Cardiovascular & respiratory depression most

immediately life threatening

 MONITOR BLOOD PRESSURE

  • Oscillometric and/or Doppler units

 Should use true respiratory monitor

  • Pulse oximeter is not a true respiratory monitor
  • ETCO2 is good measurement of ventilation

 Monitor the basics

  • MM color, CRT, jaw tone, body temperature, etc…
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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 11

 If it isn’t right – FIX IT  Hypotension (MAP<60 mmHG)

  • Decrease anesthetic depth, increase fluid rate
  • Give bolus of crystalloids, consider colloids
  • Administer positive inotrope (eg, dopamine)

 Hypoventilation (ETCO2>50 mmHg)

  • Occurs more often than we think
  • BREATHE!
  • Hypoventilation has many causes

 Hypothermia – keep patients warm Preanesthesia Induction Maintenance Recovery

  • Achieve unconsciousness smoothly &

rapidly; dose TO EFFECT

  • Dose TO EFFECT; May need to add more

analgesia; MONITOR & SUPPORT

  • May need more analgesia and/or sedation
  • MONITOR & SUPPORT
  • Patient preparation for anesthesia
  • SEDATION & ANALGESIA

 Most unexpected anesthesia-related adverse

events occur in recovery A Description of Intraoperative and Postanesthesia Complication Rates

Tarrac SE, Journal of PeriAnesthesia Nursing, 2006:21(2);88-96  26% overall complication rate

  • 3% intraop
  • 23% in the PACU (recovery unit)
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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 12

The incidence of postoperative complications in the PACU

Mayson KV, Beestra JE, Choi PT  Respiratory complications 15.2%

  • Apnea, airway obstruction, hypoxemia

 CV complications 12.3%

  • Hypertension, hypotension, arrhythmias

 Excessive pain 7.2%  ‘Cookbook’ anesthesia is okay

  • Most patients are suitable for a basic protocol
  • ADD ANALGESIA as pain intensity progresses
  • DOSE TO EFFECT

 HAVE to have more than one recipe

  • Compromised patients clearly need protocols

that fit their underlying disease

  • DOSE TO EFFECT

 Monitoring & appropriate support

for ALL patients

Della - Ovariohysterectomy

  • Della
  • 6-month old healthy

Labrador Retriever

  • PE normal
  • Serum chemistry, CBC

normal

  • Elective OHE
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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 13

 Premeds

  • Morphine or hydromorphone
  • Medetomidine or acepromazine
  • NSAID

 Induction

  • Propofol

 Maintenance

  • Sevoflurane

 Recovery

  • Analgesia, as needed
  • NSAID dispensed for post-discharge pain

 4 yr, healthy MN

mixed breed

 Acutely lame, left

rear, after Frisbee

 Stifle swollen, painful  Drawer sign elicited  Surgical repair of CCL  Premeds

  • Morphine or hydromorphone
  • Medetomidine or acepromazine
  • NSAID

 Induction

  • Propofol

 Maintenance

  • Sevoflurane
  • Epidural and/or intra-articular morphine

 Recovery

  • Analgesia, as needed
  • NSAID dispensed for post-discharge pain +

tramadol, fentanyl patch or codeine

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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 14

 Ginger, 16 yr old FS

  • Grade III heart murmur
  • Regulated diabetes
  • No other abnormalities

 Dentistry with extractions

 Premeds

  • Morphine or Hydromorphone

– decrease dose, no other sedation

  • NSAIDs?

 Induction

  • Propofol

 Maintenance

  • Sevoflurane
  • Local anesthetic dental blocks

 Recovery

  • Analgesia, as needed
  • NSAIDs for post-discharge pain +/- tramadol

 SAME PRINCIPLES  Standard protocols are good

  • Have more than one

protocol

 Balanced anesthesia and

analgesia

 Each phase of anesthesia

is equally important

 Address analgesia in all phases  MONITOR & SUPPORT

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Advanced Medical Care: Improving Veterinary Anesthesia AAHA National Staff Meeting Web Conference -Thursday, April 23, 2009 15

 Premedication

  • Sedation / analgesia

 Induction

  • Fast & smooth

 Maintenance

  • Readdress analgesia
  • MONITOR & SUPPORT

 Recovery

  • Sedation / analgesia
  • Monitor & Support

 Pain doesn’t end at discharge

THANK YOU ABBOTT!

1. Complete the evaluation by Monday, May 4, 2009. Please have

  • nly one person from your practice complete this evaluation.
  • To complete the evaluation, please go to the following

website: http://www.keysurvey.com/survey/244772/27db/ 2. After completing the evaluation, you will automatically be linked to the Continuing Education Certificate. The CE certificate can only be accessed after the evaluation is completed. 3. Download the CE Certificate (in pdf format) to your computer and print enough copies for your entire team. Your input is very important! We take feedback seriously in order to provide you with the highest quality experience possible. If you have any questions about completing the evaluation or accessing your CE certificate, please email us at webconference@aahanet.org or call 800/252-2242.

AAHA gratefully acknowledges the following for their sponsorship of this Web Conference.

Questions to the Speaker

If you didn’t get a chance to submit your questions through the online chat feature or have additional questions, please email your questions to webconference@aahanet.org by Thursday, April 30, 2009.

  • Dr. Grubb will provide written responses to all of the questions and they will be posted
  • n AAHA’s website by Monday, May 4, 2009.