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
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
Hb Neonates <12 w.o Geriatrics >8 y.o CV disease Resp disease PU/PD
PT/APTT
PLT
ECG
Blood pressure
ANAEMIA
Lowhaemoglobin/packedcellvolume Decreasedoxygendeliverytotissues
(echo)
(if arrhythmia)
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
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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
MEASURINGTHEDEPTH(ADEQUACY)OF ANAESTHESIA
MEASURINGTHEDEPTH(ADEQUACY)OF ANAESTHESIA
MEASURINGTHEADEQUACY(DEPTH)OF ANAESTHESIA
From:BSAVAManualofCanineandFelineAnaesthesiaandAnalgesia(2nd Edition)
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SIDEEFFECTSOFANAESTHESIA
ANAESTHETICRISK:MORTALITY
Generalanaesthesiaalwayscarriessomerisk
(Humansapprox.1in10000overall)
ANAESTHETICRISK:MORBIDITY
Pathologyresultingfromanaesthesia notresultinginimmediate death(orwithin7days) Failureofanimaltoreturntopreoperativestate Examples Muscledamage Nervedamage Cerebralhypoxia(blindness), memoryloss Renaldysfunction Pulmonarydysfunction
WHATAFFECTSRISK?
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
ADDETONUMBERIFPROCEDUREISANEMERGENCY
HOWCANWEREDUCERISK?
Examinepatient(includeshistory) Preparepatientproperly!!!!!(mayincludefurthertests) Checkallanaestheticequipmentbeforeuse Appropriateuseofdrugs Constantmonitoring(keepanaestheticrecord) Intraoperativesupport(fluids,keepwarm,drugs) Propercareinpostopperiod(manyanimalsdieinrecovery)
WASTEANAESTHETICGASES
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
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MONITORINGINTHEWORKPLACE
TOPICSFORTHISCOURSE
Apparatustoadministeranaestheticagents Painandanalgesia Pain and analgesia Sedation Inductionofanaesthesia Maintenanceofanaesthesia Monitoringandcareoftheunconsciousorsedated patient
TOPICSFORTHISCOURSE