reptile anesthesia and analgesia - lafeber®§ general anesthesia = induced unconsciousness...
TRANSCRIPT
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Reptile Anesthesia and Analgesia
Javier G. Nevarez DVM, PhD, DACZM, DECZM (Herpetology)LafeberVet R.A.C.E. Provider # 776-26273
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Outline§Definitions§Relevant anatomy §Analgesia§Anesthesia§Protocols and examples§Monitoring and support§Recovery§Keys to success
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Definitions
§ Tranquilization = the relief of anxiety and a state of relaxation while the patient is aware of its surroundings.
§ Sedation = a state of central depression and drowsiness with the patient unaware of its surroundings.
§ General anesthesia = induced unconsciousness characterized by controlled reversible depression of the central nervous system and analgesia. Patients under general anesthesia are not rousable and the reflex functions are attenuated. Surgical anesthesia is a deeper level that allows for painless surgery.
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Definitions
§Analgesia = the freedom or absence of pain.
§Local analgesia = loss of sensation in a circumscribed area.
§Regional analgesia = loss of sensation or insensibility in a larger but limited body area.
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Goals
§Balancedanesthesia§Pre-emptiveanalgesia
§ Facilitateshandlingandinduction§Reduceanestheticrequirements
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AnatomyandPhysiology
§Poikilothermicspecies§Lackepiglottis§Lungsdifferinlizards,cheloniansandsnakes§Lackfunctionaldiaphragm§Threechamberheart(fourincrocodilians)§Renal-portalsystem
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What about PAIN?
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Signs of Pain
§ Change in normal behavior§ Reluctance to move§ Abnormal ambulation§ Dull and closed eyes§ Anorexia§ Hunched posture§ Aggression in passive animal§ Passive behavior in normally
aggressive animals
§ Elevated and extended head§ Lameness§ Decreased tendency to coil
(snakes)§ Aerophagia§ Color changes (darker or paler)
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Analgesia- Morphine
§Puremuagonist§ Increasedtolerancetothermalstimulusinred-earedsliders(RES),beardeddragons(BD),crocodilesandanolelizards,andelectricaliniguanasandBD
§ DecreaseddurationoflimbretractioninformalintestinSpeke’shingedtortoise
§ Associatedwithsevere(upto80%)respiratorydepressioninRES
§Dosage:1.5-5mg/kgq24h
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Analgesia- Hydromorphone
§Puremuagonist§ Increasedtolerancetothermalstimulusinred-earedslider(RES)
§Dosage:0.5-1mg/kg
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Analgesia- Fentanyl
§Puremuagonist§ Increasedtolerancetothermalstimulusinballpythonsandcornsnakes§ Plasmaconcentrationsdetectableinballpythonsandprehensile-tailedskinkswithfentanylpatch
§Dosage2.5-12.5mcg/hq24-72h
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Analgesia- Tramadol
§Weakmuagonist,inhibitsreuptakeofserotoninandnorepinephrine§ Increasedtolerancetothermalstimulusinred-earedsliders(RES),andtoelectricalstimulusinbeardeddragons
§ Plasmaconcentrationsdeterminedinseaturtles,beardeddragons§ RespiratorydepressioninRESwaslessthanwithmorphine
§DosagesinRES5-10mg/kgq72hPO
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Analgesia- Meloxicam
§NSAID,cyclooxygenase(COX)-2specificinhibitor§ Increasedthetolerancetoelectricalstimulusinbeardeddragonat0.4mg/kgIM
§ Didnotchangephysiologicparametersinballpythonsat0.3mg/kg,orhematologicalandbiochemicalparametersiniguanasat0.2mg/kg
§ PlasmaconcentrationsdeterminedinRESandiguanas
§Dosage0.5mg/kgq24h
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Regional Analgesia/anesthesia
§Intrathecalspinalanalgesiainred-earedsliders
§ Lidocaine– 1hr.§Bupivacaine– 2hr.§Morphine– 48hr.§Preservative-freeformulations
§ Mans,C.Clinicaltechnique:intrathecaldrugadministrationinturtlesandtortoises.JournalExoticPetMedicine23(2014),pp.67-70.
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Indications for Tranquilization
§Restraint of fractious animals§Ultrasound§Radiographs§Transport§Venipuncture§Fine needle aspiration
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Indications for Sedation
§Restraint of fractious animals§Ultrasound§Radiographs§Transport§Venipuncture§Fine needle aspiration
§Minimally invasive procedures combined with local analgesia
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IndicationsforAnesthesia
§Surgery§Endoscopy§Invasive procedures§Ultrasound-guided biopsy, etc..
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Injectable Agents§Ketamine§Dexmedetomidine§Midazolam§Propofol§Alfaxalone
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Alfaxalone
§Neuroactivesteroidagent§Rapidinductionandrecovery§ Intravenous(IV)andintramuscular(IM)routes§ Induction(5-10mg/kg),maintenance,constantrateinfusion(CRI)andbolus
§Minimalcardiorespiratorydepression*
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InhalationalAgents-Isoflurane
§Minimalmetabolism,eliminatedbylungs§Right-to-leftcardiacshuntingmightresultinmismatchgasconcentration andpooranestheticdepth
§Dosedependentcardiovasculardepression§Minimumanestheticconcentration(MAC)1.8-2.1%iguana,1.37-1.71%monitors,1.31-2.49%ratsnake
§ Inductionvariable%,maintenance2-3%
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InhalationalAgents- Sevoflurane
§ Fasterinductionandrecoverythanisofluraneiniguana,butsimilarrecoveryinmonitors
§Nosignificantcardiopulmonarydifferenceswithisofluraneiniguanas
§ Lessirritanttoairwaysthanisoflurane§MAC3.0-3.2%iguana,2.05-2.97%monitors,1.85-2.99%ratsnakes
§ Inductionvariable%,maintenance3.5-4.5%
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Premedication§Combination of:§Ketamine§Dexmedetomidine§Midazolam§Propofol§Alfaxalone§Hydromorphone/morphine
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Induction
§Propofol§Alfaxalone
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Maintenance§Isoflurane or sevoflurane
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Example 1 Tranquilization to sedation§Sulcatta for exam and venipuncture§Option A§Midazolam, ketamine +/- dexmed. IM or IV
§Option B§Alfaxalone IM
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Example 2
§Esophagostomy tube§Midazolam IV or IM for sedation§Hydromorphone or morphine IM §Meloxicam §Local lidocaine block
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Example 3§Radiographs, gastroscopy +/- coelioscopy of Alligator snapping turtle
§Premed/induction§ Hydromorphone 1mg/kg§ Ketamine 2-5 mg/kg§ Dexmedetomidine 0.025-0.05 mg/kg§ Midazolam 0.5-1 mg/kg§ IV injection
§Maintenance§ Isoflurane
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Example 4§Radiographs, Gastroscopy +/- coelioscopy of Alligator snapping turtle
§Premed/induction§Hydromorphone 0.5 - 1mg/kg§Propofol 10mg/kg or Alfaxalone 10-20 mg/kg
§Maintenance§ Isoflurane
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Example 5
§Green iguana coelomic surgery§Premed/induction§Hydromorphone 1mg/kg§Ketamine 2-5 mg/kg§Dexmedetomidine 0.025-0.05 mg/kg §Midazolam 0.5-1 mg/kg§ IV injection
§Maintenance§ Isoflurane
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IV IM
InjectionSites
§ Subcarapacial sinus§ Jugular§ Tail veins§ Brachial plexus§ Occipital sinus§ Ventral abdominal vein§ Palatine vein§ Etc..
§ Limbs§ Tail§ Epaxials
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InjectionSites
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Intubation- Chelonians
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Intubation- Snakes
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Intubation- Lizards
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Intubation- Crocodilians
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PatientMonitoring
§Cornealreflexisgoodindicatorofdepthanddeath
§Heartrate:Doppler,ECG,Ultrasound
§Respiratoryrate:oftenneedintermittentpositivepressureventilation(IPPV)
§ DO NOT EXCEED 15–20 mmHg§ POP-OFF valve MUST REMAIN OPEN after breathing§ 2–4 breaths/min
§Temperature:KEYforsuccessfulanesthesia§ Aim for 90 - 95oF (32-35oC) during anesthesia
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CardiovascularSupport
• Fluidtherapy• Intravenous• Intraosseous• Subcutaneous• Intracoelomic
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IO Access
§Femur§Tibia§Carapace/plastron§ IO access can be used the same as IV but with slower volume of infusion
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IO Catheter
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TemperatureSupport
§Forcedairwarmer§Heatblankets§Heatlamps§Warmfluids§Rice/beanbags§Etc..
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Hypothermia
§Heat loss§Convection§ Air exchange at body surface
§Radiation§ Heat loss to surfaces and environment
§Conduction§ Heat loss from contact (i.e. cold table)
§Evaporation§ Heat loss from lungs, skin, exposed tissues
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Preventing Hypothermia
Convection Conduction Evaporation Radiation
Forced-air warmer
X X X
Heating pads
X
Heat lamp X
Rice/bean stockings
X
Water baths X X
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Recovery
§Wean off gas before the end of procedure
§Maintain O2 at low flow rate
§KEEP WARM!!!!!!!!!!!!!!!!
§Breathing stimulus§Reptiles: O2
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Key to Success
1. Keep patients warm
2. Keep patients hydrated
3. Balanced anesthesia and analgesia
4. Discontinue O2 before end of surgery
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Not every patient needs drugs
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RADS and CT
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References
§SladkyKS,MansC.Clinicalanalgesiainreptiles.JEPM21(2012),pp17-31
§SladkyKS,MansC.Clinicalanesthesiainreptiles.JEPM21(2012),pp17-31
§SchumacherJ,YelenT:Anesthesiaandanalgesia,inMaderD(ed):ReptilemedicineandSurgery(2nd ed),2012,pp442-452
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Questions?