anesthesiology of dog and cat · 2018-10-17 · anesthesiology of dog and cat a-a gradient healthy...
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Anesthesiology of dog and cat
Anesthesiology of dog and cat
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
Fundamentals of„safe“ anesthesia
1. Venous access
2. Endotracheal intubation
3. Oxygenation
4. Artificial lung ventilation
5. Knowledge and possibility of CPCR
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Anesthesiology of dog and cat
Anesthesia of DOG
• Monoanesthesia
– Propofol i.v.
– Inhalation anesthesia (Iso, Sevo, Des)
• Examination
• Painless procedures only
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Anesthesiology of dog and cat
• Sedation and premedication
– Dex/medetomidine (+ opioids) i.m., i.v.
– Midazolam (Diazepam) + opioids i.v.
– Acepromazine + opioids i.m., i.v.
– Droperidol + Fentanyl i.m., i.v.
Anesthesia of DOG
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Anesthesiology of dog and cat
• Anesthesia induction
– Intravenous
• Propofol, Thiopental, Thiopental, Etomidate, Alfaxalon
• Diazepam/Ketamin
– Intramuscularly
• Ketamin, Zolazepam/Tiletamin, Alfaxalon
– Inhalation (by mask) – Iso, Sevo, Des
Anesthesia of DOG
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Anesthesiology of dog and cat
• Maintenance
– Readministration of boluses
• Propofol, Alfaxalon, Ketamin i.v.
• Ketamin, Zolazepam/Tiletamin, Alfaxalon i.m.
– Infusion (CRI – Constant Rate Infusion)
• Propofol, Alfaxalon i.v.
– Inhalation
• O2 + (N2O, Air) + Iso, Sevo, Des
Anesthesia of DOG
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Anesthesiology of dog and cat
Anesthesia of CAT
• Monoanesthesia
– Ketamin, Zolazepam/Tiletamine i.m.
– Propofol, Alfaxalon i.v.
– Inhalation anesthesia (Iso, Sevo, Des)
• Examination
• Painless procedures only
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Anesthesiology of dog and cat
• Sedation and premedication
– Dex/medetomidine (+ opioids) i.m., i.v.
– Midazolam (Diazepam) + opioids i.m., i.v.
– Zolazepam/Tiletamine i.m.
– (Acepromazine + opioids i.v.)
Anesthesia of CAT
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Anesthesiology of dog and cat
• Anesthesia induction
– Intravenously
• Propofol, Ketamin, Alfaxalon
– Intramuscularly
• Ketamin, Zolazepam/Tiletamine, Alfaxalon
– Inhalation (by mask, chamber)
• Iso, Sevo, Des
Anesthesia of CAT
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Anesthesiology of dog and cat
• Maintenance
– Bolus readministration, CRI
• Propofo, Ketamin, Alfaxalon i.v.
• Ketamin, Zolazepam/Tiletamin, Alfaxalon i.m.
– Inhalation
• O2 + (N2O, Air) + Iso, Sevo, Des
Anesthesia of CAT
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Anesthesiology of dog and cat
Patient with
cardiovasculardisease
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
Patient with cardiovascular disease
• Reduction of drug absorption after i.m., s.c.
• Reduction of distribution, metabolization, elimination
• Formation of edemas
• Hypoproteinemia
• Faster onset of inhalation anesthetics
• Impairment of ventilation/perfusion – venous admixture
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Anesthesiology of dog and cat
Anesthetics
• Influences
– Autonomic functions
– Vascular tone
– Heart rate
– Myocardial contractility
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Anesthesiology of dog and cat
HR MAP C.O. SVR
Atropine ↑↑↑ ↑ ↑ 0
Dex/Medetomidine ↓↓↓ ↑/↓ ↓↓ ↑↑/↓
Acepromazine 0 ↓↓ ↓ ↓↓
Diazepam, Midazolam 0 0 0 0
Butorphanol ↓ ↓ 0 0
Buprenorphine ↓ 0 ↓ ↑
Fentanyl ↓↓ ↓ 0 0
Morphine ↓ ↓ 0 0
Methadon ↓↓ 0 0 0
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Anesthesiology of dog and cat
HR MAP C.O. SVR
Propofol ↓ ↓↓ ↓ ↓↓
Ketamine, Tiletamine ↑ ↑ ↑ ↑
Etomidate 0 0 0 0
Thiopental ↑↑ ↓ ↓ ↓
Isoflurane ↑↑ ↓↓ ↑ ↓↓
Sevoflurane 0 ↓ 0 ↓
Desflurane ↑ ↓↓ 0 ↓↓
Nitrous oxide ↑ 0 ↑ ↑
Lidocaine Ca ↑ Fe ↓ Ca 0 Fe ↑ Ca 0 Fe ↓ Ca 0 Fe ↑
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Anesthesiology of dog and cat
Stabilization before anesthesia
• Current medication
– Furosemide, ACE, Pimobendan, Benazepril, …
• Evacuation (drainage) of effusion
• Left-side insufficiency
– Furosemide 1–2 mg/kg
• DCM, mitral valve degeneration
– Pimobendan 0,1–0,3 mg/kg
• Correction of arrhythmias
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Anesthesiology of dog and cat
Goals of anesthesia
• Stable HR
– Catecholamine, vagal tone
– Anesthesia depth, level of analgesia
• Stable MAP
– Fluid therapy
• Sufficient oxygenation
– Hemoglobin, ventilation
– Anemia, normoxia
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Anesthesiology of dog and cat
• Preparation of drugs, anesthetics, equipment, …
– Atropine, Epinephrine, Lidocaine
• Continual monitoring
• Pre/oxygenation
• Sedation
– Sufficient reduction of stress
• Adequate analgesia
• Smooth induction
Anesthetic protocol
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Anesthesiology of dog and cat
Anesthetic protocol
• Balanced anesthesia
• Constant, adequate depth of anesthesia
• Sufficient analgesia
• Normoxia – oxygenation
• Ventilation – minimal PIP/PEEP
• Adequate monitoring
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Anesthesiology of dog and cat
Fluid therapy
• Cardiac patient – increased circulatory volume
• Vasodilatators, diuretics – hypovolemia
• Surgery without fluid loss
– Avoid fluids with increased concentration of Na (0,9% NaCl)
– Ringer lactate 2 ml/kg/h
– Precisely dosed colloids
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Anesthesiology of dog and cat
• Intra-cardiac pressures
Cardiologic patient
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Anesthesiology of dog and cat
PDA
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• L-R PDA – decreasing of C.O. – hypotension – hypertrophy
• R-L PDA – venous admixture – cyanosis
• Anesthesia
– Maintain HR, C.O.
– Maintain PVR, SVR
– Oxygenation
– (Acepromazine 0.002–0,005 mg/kg
– Ligation – Branhams reflex – bradycardia, vasodilatation
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Anesthesiology of dog and cat
Aortic stenosis
• Reduction of LV output – hypertrophy
• Decrease of DAP – decrease of coronary perfusion
• Anesthesia
– Normotension, avoid hypertension
– Maintain HR
– Oxygenation
– (Dexmedetomidine 0.001 – 0.002 mg/kg
Sey
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Nov
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AVA
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Anesthesiology of dog and cat
Stenosis of a. pumonalis
• Insufficiency of v. tricuspidalis – RA hypertrophy –RV hypertrophy
• Anesthesiaa
– Keep venous return, preload
– Maintain contractility – HR
– Maintain PVR (IPPV/PEEP)
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Anesthesiology of dog and cat
Ventricular septal defect
• Larger defects – commonly with AS, PS, PDA
• Smaller defects – without severe abnormalities
• Anesthesia
– Maintain PVR
– Maintain SVR
– Keep L-P shunt
– Oxygenation
Sey
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Nov
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2007
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Anesthesiology of dog and cat
Valvular defects
• Bradycardia, hypotension, lung edema
• Accurate dosing of fluids
• Anesthesia
– Reduce bradycardia
– Slight tachycardia
– Maintain C.O.
– Keep (decrease?) SVR, PVR
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Anesthesiology of dog and cat
• Emptying of LV reduced
• Myocardial ischemia, arrhythmia
• Anesthesia
– Avoid tachycardia
– Avoid contractility
– Increase preload, SVR
– Ketamine unsuitable
– Dexmedetomidine 0.005–0.007 mg/kg
Hypertrophic cardiomyopathy
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Anesthesiology of dog and cat
• Ca – deficit of LV
• (Fe – deficit of RV)
• Decrease SV, Arrhythmias, lung edema
• Anesthesia
– Maintain C.O.
– Reduce arrhythmias
– Oxygenation
– Alpha-2 agonists unsuitable
Dilated cardiomyopathy
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Anesthesiology of dog and cat
Cor pulmonale
• Pathology of lungs and RV – affected tricuspid and pulmonary valve
• Anesthesia
– Maintain/decrease lungs PVR
– Iso, Sevo, Des – decrease PVR
– Low PIP/PEEP
– N2O, ketamin, dopamin, hypercapnia
• Increase PVR – unsuitable
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Anesthesiology of dog and cat
Systemic hypertension
• Stress – sympatric stimulation – myocardial hypoxia – arrhythmias
• Anestezia
– Stable HR, SV
– Stable MAP
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Anesthesiology of dog and cat
Anesthesia of cardiologic patient I.
• (Midazolam 0.25 mg/kg i.v.)
• Fentanyl 0.005–0.01 mg/kg i.v.
• Propofol, Alfaxalon (to the effect)
• O2 – Iso, Sevo, Des
• Fentanyl 0.005–0.02 mg/kg/h i.v.
• (Artificial ventilation?)
• (Analgesia?)
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Anesthesiology of dog and cat
• (Midazolam 0.25 mg/kg i.v.)
• Fentanyl 0.005–0.01 mg/kg i.v.
• Propofol, Alfaxalon (to the effect)
• O2 – Iso, Sevo, Des
• Fentanyl 0.005–0.02 mg/kg/h i.v.
• (Artificial ventilation?)
• (Analgesia?)
Anesthesia of cardiologic patient II.
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Anesthesiology of dog and cat
• Midazolam 1.2 mg/kg + 0.9 mg/kg/h i.v.
• Sufentanil 0.0038 mg/kg + 0.003 mg/kg/h i.v.
• IPPV/PEEP
Anesthesia of cardiologic patient II.
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Anesthesiology of dog and cat
Patient with
respiratorydisease
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
Respiratory abnormalities
• Hypoxia, hypercapnia – cardiovascular abnormalities – multiorgan effects
• Anesthesia – impairment of
– Mucocilliar function (Atropine)
– Formation of atelectases
– Impairment of ventilation/perfusion – AV shunts(Propofol)
– Respiratory depression
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Anesthesiology of dog and cat
Healthy lungs Pathology
FiO2 21 % (0,21) 21 % (0,21)
PaO2 110 mmHg 50 mmHg
PaO2 / FiO2 524 238
PaO2 / FiO2
> 500
(normal)
< 300
(abnormal)
PaO2 / FiO2 ratio
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Anesthesiology of dog and cat
A-a gradient
Healthy lung Pathology
FiO2 21 % (0,21) 21 % (0,21)
PaO2 74 mmHg 74 mmHg
PaCO2 58 mmHg 31 mmHg
PAO2 = FiO2 (PB – PH2O) – (PaCO2 / RQ)
PAO2 76,6 mmHg 110,4 mmHg
A-a gradient
= PAO2 – PaO2
2,6 mmHg 36,4 mmHg
A-a gradient < 15 mmHg (normal) > 25 mmHg (abnormal)
PB – barometric pressure (760 mmHg), PH2O – partial pressure of water vapor (50 mmHg), RQ – respiratory quotient (0,8)
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Anesthesiology of dog and cat
Bronchial effects
• Bronchodilatation
– Atropine, Ketamin, (Propofol)
– Ketamin/propofol ("Ketofol", 0.5/0.5 doses in one syringe)
• Bronchoconstriction
– Thiopental
• Antitussic effect
– Butorphanol, Codeine
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Anesthesiology of dog and cat
Anesthetic technique
• Preoxygenation (3 minutes)
• Induction
– Fast – i.v. + ETR
– Benzodiazepines + opioids
+ Propofol, Alfaxalon
• Adequate ETR
• TIVA
• Precise checking of ventilation (IPPV/PEEP)
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Anesthesiology of dog and cat
Monitoring
• SpO2
– More than 95 %
• EtCO2
– 30–45 mmHg (4,0–6,0 kPa)
• Spirometry
– VT 7–15 ml/kg
– MV 100–300 ml/kg/min
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Anesthesiology of dog and cat
Bronchoscopy
• Pre/oxygenation
• Feline asthma – Albuterol
• Adapter for bronchoscopy
• Larmasks
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Anesthesiology of dog and cat
• Pre/oxygenation
• Albuterol
• Midazolam
Butorphanol
Ketamin – bronchodilation
• Stimulation of pharynx – spasm
– Lidokain local
Feline asthma
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Anesthesiology of dog and cat
Contusion, pneumonia, bullae, …
• Pre/oxygenation
• Risk of bleeding, rupture
• Spontaneous breathing
• IPPV/PEEP
– fR 8–10 breaths/min
– PIP ˂ 10 cmH2O
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Anesthesiology of dog and cat
Patient withhepaticdisease
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
Liver
Glucose
Detoxication
Proteins Lipids
CoagulationProduction
regulation
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Anesthesiology of dog and cat
Blood plasma protein binding
• High (> 80%)
– Propofol, Diazepam
• Medium (50-80%)
– Thiopental
• Low (< 50 %)
– Ketamine, Morphine
• Change of anesthetic effectiveness
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Anesthesiology of dog and cat
Hepatic disease I.
• Drugs with minimal liver metabolisation
– Opioids – Fentanyl derivates
– Inhalation anesthetics – Iso, Sevo, Des
– Short acting anesthetics – Propofol, Etomidate, Alfaxalon
– Atracurium, Remifentanil (Hoffmanns degradation)
– Ester L.A. – Procaine
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Anesthesiology of dog and cat
• Unsuitable drugs
– Morphine (↑ of tone of Oddi´s sphincter ↑ histamine,
↓ perfusion)
– Neuroleptics (vasodilation, duration time, seizures?)
– Alpha-2 agonists (vasoconstriction)
– Ketamin (vasoconstriction)
– Thiopental (protein binding)
– Amid L.A. (prolonged metabolisation]
Hepatic disease II.
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Anesthesiology of dog and cat
• High risk patients
• Liver hypoplasia
– Hepatoencephalopathy
– Hypoglycemia
– Blood coagulation impaired
– Hypoprotemia
• Surgery
– Serious changes of blood pressure
Portosystemic shunt (PSS) I.
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Anesthesiology of dog and cat
50
• Postoperative care
– Normothermia
– Normoglycemia
– Normotension
– Control of seizures
– Normoproteinemia
– Oxygenation
Portosystemic shunt (PSS) II.
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Anesthesiology of dog and cat
Liver biopsy
• Sedation, decrease of fR
• Hemostatic examination
• (Vitamin K?)
• Premedication
– Opioids (Fentanyl derivates, Pethidine)
• Anestezia
– Propofol, Alfaxalon
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Anesthesiology of dog and cat
Abnormalities of biliary tract
• In small animals rare
• Oddi´s sphincter– increases pressure in biliary tract– Opioids– Morphine – Pethidine, Fentanyl –
Butorphanol – Buprenorphine, Nalbuphine
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Anesthesiology of dog and cat
Anesthesia for hepatopathy I.
• Hemostazeology
• Short acting anesthetics
• Hydratation
• Normoglycemia, normoproteinemia
• Normotension
• Eukapnia
• Control of seizure
• Risk of thromboembolia
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Anesthesiology of dog and cat
• Premedication
– Opioids (Morphine unsuitable)
– (Atropine?)
• Induction
– Mask? – cooperating patients only
– Propofol, Etomidate, Alfaxalone
• Maintenance
– Iso, Sevo, Des
– (Atracurium?)
Anesthesia for hepatopathy II.
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Anesthesiology of dog and cat
Patient with
urologicdiasease
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
Pathophysiology I.
• Autoregulation of glomerular filtration
– MAP 80–180 mmHg
– Hypovolemia – vasoconstriction
• Fenothiazines
• Up to 50% lower GF
• Correction (> 4 hours)
• Anesthesia
– Autoregulation impaired
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Anesthesiology of dog and cat
• Sympaticus – renal vasoconstriction
– Insufficient anesthesia, analgesia, hypoxia, hypercapnia
• Antidiuretic hormone
– Secretion – stress, anesthetics
• Barbiturates, opioids, inhalation anesthetics
– Decreased secretion
• Fenothiazines (+ vasodilation) – diluted urine
Pathophysiology II.
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Anesthesiology of dog and cat
Nephrotoxins
• Aminoglycoside antibiotics
• Amphotericin B
• Hemoglobin, bilirubin, myoglobin
• Fluoride ions
• X-ray contrast media
• Oxalates
• Metoxyflurane
• Non-steroidal anti-inflammatory agents
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Anesthesiology of dog and cat
Urologic patient I.
• Influence of anesthetic on renal functions
• Influence of renal abnormalities on drug metabolisation
• Regulation of
– Fluid and electrolyte balance
– Acid-base balance
• Excretion of N-metabolites, anesthetics
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Anesthesiology of dog and cat
• Without abnormalities
• Abnormalities
– Hyperkalemia, hyperphosphatemia, hypocalcemia, hyponatremia
– Acidosis
– Hypovolemia
• Emergency states
– Urinary tract obstructions
– Urinary bladder rupture
Urologic patient II.
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Anesthesiology of dog and cat
Influence of anesthetics
Kidney perfusion GFR
Etomidate +++ +++
Thiopental +++ ++↓
Ketamin ↑↑ ++↓
Iso, Sevo ↓ ↓↓
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Anesthesiology of dog and cat
Nephropaties
• Drugs effect prolonged
– With active metabolites
• Morphine, Ketamine, Diazepam
– Primarily excreted by kidneys
• Pankuronium, Ketamine
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Anesthesiology of dog and cat
Patient with
neurologicdisease
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
• ICP = 0-10 mmHg
CPP = MAP – ICP
• MAP = 70-80 mmHg
• PaCO2 = 35-40 mmHg
• PaO2 = 90-100 mmHg
Sey
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Patophysiology
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Anesthesiology of dog and cat
Normotension and normocapnia
Seymour Ch, Duke Novakowski T 2007: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia
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Anesthesiology of dog and cat
Regulation of ICP
• Patient positioning
• Stabilization of MAP, CVP
• Normocapnia (IPPV), oxygenation
• Sedation
• Lidocaine
• Furosemide
• Mannitol
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Anesthesiology of dog and cat
Influence of anesthetics on ICP
Ketamin
N2O
Acepromazine
Opioids
Dex/medetomidine
Benzodiazepines
Isoflurane, Sevoflurane
Propofol, Thiopental
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Anesthesiology of dog and cat
Anesthesia
• Sedation and premedication
– Opioids (Morphine?)
– Alpha-2 agonists (Xylazine?), Benzodiazepines
• Induction and maintenance
– Propofol (CRI)
– Iso, Sevo, Des
– Induction by mask – unsuitable (excitation)
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Anesthesiology of dog and cat
Analgesia
• Opioids
• Alpha-2 agonists
• NSAIDs, steroids
• Ketamine – low doses, CRI
• Lidocaine – CRI
• Gabapentin (anticonvulsant)
• Amitriptiline (tricyclic antidepressives)
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Anesthesiology of dog and cat
Patient with epilepsy
• Acepromazine? (Tobias a kol. 2006)
• Opioids
• Low doses of alpha-2 agonists
• Benzodiazepines (in combination)
• Propofol, Thiopental
• Ketamine unsuitable
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Anesthesiology of dog and cat
Patient with
gastrointestinaldisease
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
Gastrointestinal abnormalities
• Abnormalities
– Electrolyte, acid-base
– Dehydratation, hypovolemia
– Malabsorption, hypoproteinemia
• Emergency cases
– Volvulus, perforation, …
• Pancreas
– Changes of glucose metabolism
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Anesthesiology of dog and cat
Pharmacology of anesthetics
• Atropine – ↓ motility, tone, secretion of GIT
• Opioids – obstipation (Morphine), stimulation (Fentanyl)
• Benzodiazepines – minimal influence, stomachic (Diazepam)
• Acepromazine – antiemetic, ↓ secretion of ADH
• Alfa-2 agonists – ↓ motility, GOR, vomitus, ischemia
• Thiopental – ↑ duodenal and jejunal motility
• Propofol, Etomidate – minimal influence
• Nitrous oxide – gas accumulation
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Anesthesiology of dog and cat
Abnormalities of oral cavity
• Toot and periodontal disease
• Pathology of salivary glands
• Pathology of pharynx
– ETR intubation
– Nerve blocks
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Anesthesiology of dog and cat
Abnormalities of esophagus I.
• Obstruction
– KI drugs inducing vomiting
– Opioids + Propofol, Thiopental, Ketamin, Etomidate, Apfaxalone
– ETR (cuff) necessary
– Ca – striated muscles – PMNBA + UPV
– ? thoracic surgery ?
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Anesthesiology of dog and cat
• Megaesophagus
– Risk of aspiration pneumonia
– Vascular ring anomaly
• Esophagitis
– Complication of GOR
• (17% of pacients undergoing G.A.)
• Sucralfate, H-2 blockers, Metoclopramide
• Atropine – relaxation of esophageal sphincter
Abnormalities of esophagus II.
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Anesthesiology of dog and cat
Abnormalities of stomach
• GDV
– Shock
– Benzodiazepines + opioids + Propofol, Etomidate, (Ketamin) + Iso, Sevo, Des
– Cardiac arrhythmias – Lidocaine
• Gastroduodenoscopy
– Opioids – ↑ tone of pyloric sphincter
– Acepromazine
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Anesthesiology of dog and cat
• Small intestine
– Opioids (increased pyloric tone)
– Acepromazine, Midazolam
– Propofol, Etomidate, Alfaxalon
– Iso, Sevo, Des
• Large intestine
– ? Epidural anesthesia ?
– Rectum – recumbency – UPV
Intestinal abnormalities
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Anesthesiology of dog and cat
Visceral analgesia
• Opioids + NSAIDA
– Buprenorphine + Metamizol, Carprofen, Meloxicam
• CRI
– Lidocaine
– Ketamin
– Dex/medetomidine
– Fentanyl, Morphine
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Anesthesiology of dog and cat
Patient for
Cesarean section
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
Pregnancy
• Decrease of lung capacity, increase consumption of O2
– Risk of atelectases, hypoxia
• Increase of alveolar ventilation
– Risk of inhalation anesthetics overdose
• Sedative effects of progesterone
– Risk of anesthetic overdose
• Distension of abdominal cavity
– Hypoventilation, hypotension
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Anesthesiology of dog and cat
Cesarean section
• Influence of female and fetal health status
• Influence of character of CS
• Increased fetal mortality
– Alpha-2 agonists
– Long-acting anesthetics
• Minimal negative effects
– Iso, Sevo, Dex, Propofol, Alfaxalone
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Anesthesiology of dog and cat
• Short-acting anesthetics
• Anesthetics with antagonists
• L.A. – EPI
• Oxygen supplementation
• ETR
• Fluid therapy
• ABP monitoring
Anesthesia for CS
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Anesthesiology of dog and cat
Anesthetics for CS I.
• Mu-opioids
– Respiratory depression, bradycardia
– Antagonisation
• Phenothiazines
– Prolonged metabolisation
– Vasodilatation
• Benzodiazepines
– Crossing placental barrier
– Depression of neurological functions
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Anesthesiology of dog and cat
• Alpha-2 agonists
– Reduction of perfusion of uterus
• Propofol
– Placental barrier crossing restricted
• Barbiturates
– Reduction of newborns vitality
• Ketamin
– Respiratory depression in newborns
Anesthetics for CS II.
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Anesthesiology of dog and cat
• Alphaxalone
– CS in cats
– Fast clearance
• Local anesthetic
– Lidocaine
Anesthetics for CS III.
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Anesthesiology of dog and cat
• Local anesthesia
– Opioids + Lidocaine EPI
– Infiltrative line block
• General anesthesia
– Inhalation anesthesia (induction by mask)
– Opioids + Etomidate + Isoflurane/Sevoflurane
– Opioids + Propofol, Etomidate + Iso, Sevo, Des
Anesthesia for CS
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Anesthesiology of dog and cat
Patient with
ophthalmicdisease
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
Intraocular pressure
INCREASING
• Increasing of BP
– Coughing, vomiting
• Hypercapnia, hypoxia
• Pressure on eye globe
• Anesthetics
– Atropine, Ketamin
DECREASING
• Decreasing of ABP
• Hypocapnia
• Most of anesthetics
• Osmotic diuretics
• Carboanhydrase inhibitors
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Anesthesiology of dog and cat
Anesthesia for ophthalmology I.
• Okulocardial reflex
– Eye – trigeminal nerv – CNS – vagal nerv – heart –bradycardia
• Central eye globe position
– Eye globe surgery
– PNMBA
– Dissociatives
– Retrobulbal block
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Anesthesiology of dog and cat
• Lid and conjunctival surgery
– Without limitation
– According health status
• Eye globe surgery
– Without dissociatives
– Muscle relaxation + artificial lung ventilation
Anesthesia for ophthalmology II.
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Anesthesiology of dog and cat
Patient with
endocrinedisease
General surgery and anesthesiology
4th study year FVM
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Anesthesiology of dog and cat
Stress response
Disease
PyrogensEikosanoids
Tissue damageInfection
HypothermiaAcidosisHypoxia
Hypotension
Immobilization
HYPOTHALAMUS
BRAIN
CORTEX
Nociception
Receptor branch
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Anesthesiology of dog and cat
Stress response
Hans Selye
Effector branch
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Anesthesiology of dog and cat
Anesthetics
• Alfph-2 agonists
• Etomidate
• Thiopental
– Blockade of stress response in effector branch
– Corticoid supplementation
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Anesthesiology of dog and cat
Adrenal gland pathology
• HYPERADRENOCORTICISM– Cushing
• HYPOADRENOCORTICISM– Addison
• FEOCHROMOCYTOMA
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Anesthesiology of dog and cat
Increased level of glucocorticoids
• PU/PD, polyphagia
• Muscle weakness
• Abdominal cavity enlargement
• Hypoxemia
• Slow wound healing
• Hypercoagulation
• Lethargy
Hyperadrenocorticism
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Anesthesiology of dog and cat
Anesthesia
• Respiratory insufficiency
– Weak abdomen, hepatomegaly
• Complicated venous access
• Hypertension and cardiomyopathy
• Risk of lung embolus
– Preoperative assessment of hemocoagulation
– Heparin, Hydroxyetylstarch
Hyperadrenocorticism
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Anesthesiology of dog and cat
Preoxygenation
Premedication
– Diazepam, Midazolam, Acepromazin + Opioids
Induction
– Etomidate, Thiopental, Propofol, Alfaxalon
Maintenance
– Iso, Sevo, Des
– Propofol TIVA
Hyperadrenocorticism
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Anesthesiology of dog and cat
Unilateral adrenalectomy
• Glucocorticoids supplementation
Bilateral adrenalectomy
• Glucocorticoids and mineralocorticoids supplementation
Hyperadrenocorticism
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Anesthesiology of dog and cat
• Bradycardia
• Dehydration
• Weakness
• Lethargy
• PU/PD
• Weight loss
• …
Hypoadrenocorticism
101
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Anesthesiology of dog and cat
Hypoadrenocorticism
Corticoid supplementation
• Small surgical procedures
Pre- and postoperatively
– Hydrocortison 4–5 mg kg-1
– Dexamethasone 0,1–0,2 mg kg-1
– Prednisolon 1–2 mg kg-1
Postoperatively – after complete recovery
– Normal behavior
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Anesthesiology of dog and cat
Hypoadrenocorticism
Corticoid supplementation
• Sophisticated surgical procedures
Pre- and postoperatively
Postoperatively – 3 days
– Prednisone 0,5 mg kg-1 BID
– Hydrocortisone 2,5 mg kg-1 BID
– Dexamethasone 0,1 mg kg-1 SID
Postoperatively – since 4th day
– Normal regime
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Anesthesiology of dog and cat
Feochromocytoma
• Intermittent episodes
– Weakness
– Hypertension
– Tachycardia
– Heart arrhythmias
• Blood volume reduced
• PU/PD
• Collapse
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Anesthesiology of dog and cat
Feochromocytoma
• Risk of catecholamine release – hypertension (in Ho)
– Tricyclic antidepressives (Amitriptyline)
– Droperidol
– Acepromazine
– Naloxone
– Metoclopramid
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Anesthesiology of dog and cat
Feochromocytoma
Anesthesia
• High risk cardiologic patient
• Tachyarrhythmia
• Peroperative hypertension – postoperative hypotension
Pre- and postoperative stabilization
• Hypertension
• Tachycardia
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Anesthesiology of dog and cat
Feochromocytoma
Preoperative stabilization
• Fenoxybenzamin 0,25 mg kg-1 BID
• Propranolol 0,2-1 mg kg-1 SID
• Atenolol 0,2-1 mg kg-1 BID
Peroperative stabilization
• Fentolamin 0,1 mg kg-1 + 1-2 µg kg-1 min-1
• Esmolol 0,1 mg kg-1 + 50-70 µg kg-1 min-1
• Lidocaine, Amiodarone
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Anesthesiology of dog and cat
• DIABETES MELLITUS
• INSULINOM
Abnormalities of homeostasis of glucose
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Anesthesiology of dog and cat
Diabetes mellitus
• PU/PD
• Ketoacidosis
• Reduced liver function
• Weight loss
• (brain damage)
• …
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Anesthesiology of dog and cat
Diabetic ketoacidosis
• Dehydration
• Hypovolemia
• Metabolic acidosis
• Hyponatremia
• Hypokalemia
• Marked hyperglycemia
• Vomiting
• Anorexia
• CNS depression
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Anesthesiology of dog and cat
Diabetes mellitus
Anesthesia
• Maintain glucose levels (slight hyperglycemia)
• Minimel changes in day regime
– Timing, shortening of anesthesia
• Ketoacidosis
– Impaired protein binding
– ↑ sensitivity to anesthetics
• Alfa-2 agonists, Morphine – unsuitable
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Anesthesiology of dog and cat
Diabetes mellitus
(Normoglycemia 8–14 mmol l-1)
• Preoperatively
– Glu ˂ 5,5 mmol l-1 2,5–5% glucose
– Glu 5,5–11 mmol l-1 ¼ dose of insulin + 2,5–5% glucose
– Glu ˃ 11 mmol l-1 ½ dose of insulin + fluids
• Peroperatively
– After 30–60 minutes
– Glu ˃ 16 mmol l-1 (longer than 60 minutes) – Insulin
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Anesthesiology of dog and cat
Diabetes mellitus
Premedication
– Diazepam, Midazolam + opioids
Induction
– Etomidate, Propofol, Ketamine, Alfaxalon i.v.
Maintenance
– Iso, Sevo, Des
– Propofol, Alfaxalon TIVA
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Anesthesiology of dog and cat
Diabetes mellitus
Postoperative care
– Antagonisation
– Monitoring of glycaemia
– Small amount of food immediately, when able to eat
– Standard evening feeding
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Anesthesiology of dog and cat
Insulinoma
Adenocarcinoma of beta-cells of Langerhans islets
• Intermittent hypoglycemia
• Ataxia
• Neurologic signs
• Stress intolerance
• Syncopes
• …
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Anesthesiology of dog and cat
Insulinom
• Glucose monitoring (15–30 min)
• Postoperative hyperglycemia
– Insulin
• Anesthesia as in diabetic patients
– Glu ˃ 2,2 mmol l-1
– Risk of postoperative pancreatitis
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Anesthesiology of dog and cat
Thyroid and parathyroid
• HYPERTHYREOSIS
• HYPOTHYREOSIS
• HYPERPARATHYREOSIS
• HYPOPARATHYREOSIS
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Anesthesiology of dog and cat
Hyperthyreosis
• Hypertrophic cardiomyopathy
• Hypertension, tachycardia, arrhythmia
• Hyperthermia
• Restricted hepatic and renal functions
• Weight loss
• Aggressiveness
• PU/PD, polyphagia
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Anesthesiology of dog and cat
Anesthesia
• ↑ metabolisation of anesthetics
• ↑ O2, glucose consumption
• ↑ CO2 production
Unsuitable
– Alpha-2 agonists
– Anticholinergics, Ketamine
Hyperthyreosis
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Anesthesiology of dog and cat
Hyperthyreosis
Surgery
• Difficultness
• Pain
• Sedation
• Muscle relaxation
DEEP SEDATION
Patient
• Cardiovascular
abnormalities
• Metabolic
abnormalities
MINIMAL SEDATION
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Anesthesiology of dog and cat
Hyperthyreosis
• Premedication
– Acepromazine
– Opioids
• Induction
– Induction chamber
– Propofol, Etomidate,
Alfaxalon
– ETR intubation
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Anesthesiology of dog and cat
• Maintenance
– 5% glucose
– Iso, Sevo, Des
– Propofol, Alfaxalon TIVA
• Emergency cases
– Propofol, Alfaxalon
– Lidokain, Propanolol, Atenolol, Esmolol
– Hypocalcemia
Hyperthyreosis
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Anesthesiology of dog and cat
Hypothyreosis
• Bradycardia
• Hypotension
• Megaesophagus
• Obesity
• Lethargy
• Hypothermia
• Reduced metabolisation
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Anesthesiology of dog and cat
Hypothyreosis
Anesthesia
• Carefully negative inotropes
– Acepromazin, Isofluran
• Megaesophagus
– intubation
• Obesity
– Ventilatory support
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Anesthesiology of dog and cat
Hypothyreosis
• Premedication
– Diazepam, Midazolam + Opioids
• Induction
– Etomidate, Thiopental, Propofol, Alfaxalon
• Maintenance
– Sevo, Iso, Des
– Propofol, Alfaxalon CRI
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Anesthesiology of dog and cat
Hyperparathyreosis
• Monitoring of blood calcium
– Correction of hypercalcemia
– Monitoring of renal functions
• Risk of hypocalcemia after surgery
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Anesthesiology of dog and cat
Hypoparathyreosis
• Most often after thyroid and parathyroid surgery
– Monitoring of blood level of Ca
• Calcium gluconate
• (Eclampsia ante-partum)
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Anesthesiology of dog and cat
Increased production of estrogens
• Non-regenerative anemia
• Thrombocytopenia
• Febrile
• Immunosuppression
Sertolli cells tumor
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Anesthesiology of dog and cat
Diabetes insipidus
Absence of vasopressin (ADH)
• Unlimited access to water
• Exact fluid therapy
• Monitoring of blood Na
– Correction of hypernatremia
– 5% glucose, 0,45% NaCl