ANGOL 4.1.ppt [Kompatibilitási mód] - kisallatsebeszet.hu · Anesthesia of risk patients inin...

2012.04.10. 21:44

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Anesthesia of risk patientsAnesthesia of risk patientsinin small animal practicesmall animal practice

ANESTHESIA ANESTHESIA 4.1 4.1 20122012

Dr. Dr. MiklósMiklós PálPál Dunay Dunay

SzentSzent István University, FacultyIstván University, Faculty ofof Veterinary Veterinary ScienceScienceDepartmenrtDepartmenrt and and ClinicClinic of of SurgerySurgery and and OphthalmologyOphthalmology

SubjectsSubjects

ASA risk classification ASA risk classification ↑↑(American (American SocietySociety of Anesthetists)of Anesthetists)

(N)CEPOD (N)CEPOD urgency of interventionurgency of intervention ↑↓↑↓((National National Confidential Enquiry intoConfidential Enquiry intoPerioperativePerioperative Deaths)Deaths)

SubjectsSubjects

Young patientsYoung patientsOld patientsOld patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsGI patientsGI patientsLiver patientsLiver patientsKidney patientsKidney patientsEndEndoocrinecrine patientspatientsSeptic patientsSeptic patientsTrauma patientsTrauma patients

SubjectsSubjects

Young patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndEndooocrincrincrineee patientspatientspatientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Young patientsYoung patientsPhysPhys.. ccharacteristics 1haracteristics 1

CNSCNS–– Blood/brain barrier Blood/brain barrier permeablepermeable ((↓↓ dose until 4 dose until 4 ww))–– Immature sympathetic regulationImmature sympathetic regulation

(pain (pain →→ sensitisensitisationsation →→ hyperalgesia, allodynia) hyperalgesia, allodynia) Heart and circulation Heart and circulation –– Vegetative innervation of heart immature Vegetative innervation of heart immature –– Heart minHeart min.. volvol.: .: frequency dependentfrequency dependent

(newborn 30%, adult 300% reserve)(newborn 30%, adult 300% reserve)–– Weak vasomotorWeak vasomotoricic functionfunction, BP , BP ↓↓

RespirationRespiration–– Alveolar surface area Alveolar surface area ↓↓, surface , surface tension tension ↑↑–– RespRespiratory rateiratory rate, , tidal minute tidal minute volvolumeume ↑↑–– OO22 requirement 2requirement 2--3 x, but chemoreceptor sens. 3 x, but chemoreceptor sens. ↓↓

Young patientsYoung patientsPhysPhys.. ccharacteristics 2haracteristics 2

Fluid homeostasisFluid homeostasis–– RBCRBC, Ht, Hb, , Ht, Hb, G, Ca, K, Prot G, Ca, K, Prot ↓↓–– Total water 80% (adult 60%), EC 40% (Total water 80% (adult 60%), EC 40% (adultadult 20%)20%)–– Overhydration Overhydration →→ oed. pulm. (vasomotor oed. pulm. (vasomotor func. func. ↓↓))yy p (p ( ))

Kidney, excretionKidney, excretion–– Glom. filtration (2 w), tubulGlom. filtration (2 w), tubularar func. (6 w) func. (6 w) ↓↓–– Sens. to fluid loss (10% olig., 15% anuria)Sens. to fluid loss (10% olig., 15% anuria)–– Urine conc. Urine conc. ↓↓, Na loss , Na loss ↑↑

Liver, metabolismLiver, metabolism–– MiMiccrosomal enzyme system (4 w) rosomal enzyme system (4 w) ↓↓

ThermoregulationThermoregulation–– RRelatively large body surf.elatively large body surf., s, shivering heat prod. hivering heat prod. ↓↓

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Young patientsYoung patientsAnesthesiaAnesthesia

Fluid therapy (iv., Fluid therapy (iv., ioio.), temp. control.), temp. controlAtropineAtropine (no(nott glycopirrolateglycopirrolate!)!)

IsofluraneIsoflurane, , sevofluranesevoflurane,,KetamineKetamine ((dogdog: : immatimmatureure liver, liver, catcat: immature: immature kidney)kidney)

++ midazolammidazolamKetamineKetamine++ medetomidinemedetomidine ((catcat: : bradycardiabradycardia, hypothermia), hypothermia)

FentanylFentanyl ((rrespirationespiration ↓↓))++ midazolammidazolam ++ memedetomidinedetomidine

Young patientsYoung patientsPuppy anesthesiaPuppy anesthesia

AtropineAtropine 0.04 mg/0.04 mg/bwkgbwkg imim..IsofluraneIsoflurane 22--3 V%, 3 V%, sevofluranesevoflurane 33--4 V%4 V%KetamineKetamine 88--12 mg/12 mg/bwkgbwkg ++

d t idid t idi 0 03 /0 03 /b kb k iimedetomidinemedetomidine 0.03 mg/0.03 mg/bwkgbwkg imim..((atipamezolatipamezolee 0.2 mg/0.2 mg/bwkgbwkg imim.).)FentanylFentanyl 0.01 mg/0.01 mg/bwkgbwkg ++midazolammidazolam 1.0 mg/1.0 mg/bwkgbwkg ++medetomidinemedetomidine 0.03 mg/0.03 mg/bwkgbwkg imim..((NaloxoneNaloxone 0.02 mg/0.02 mg/bwkgbwkg ++flumazenilflumazenil 0.1 mg/0.1 mg/bwkgbwkg++atipamezolatipamezolee 0.15 mg/0.15 mg/bwkgbwkg imim.).)

Young patientsYoung patientsKitten anesthesiaKitten anesthesia

AtropineAtropine 0.04 mg/0.04 mg/bwkgbwkg imim..IsofluraneIsoflurane 22--3 V%, 3 V%, sevofluranesevoflurane 33--4 V%4 V%KetamineKetamine 20 mg/20 mg/bwkgbwkg ++

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g/g/ ggmedetomidinemedetomidine 0.05 mg/0.05 mg/bwkgbwkg imim..((atipamezoleatipamezole 0.3 mg/0.3 mg/bwkgbwkg imim.).)

SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndEndooocrinecrinecrine patientspatientspatientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Life Life expectancyexpectancy

DogsDogs–– 00--1010 kgkg 11,511,5 yy–– 1010--1515 kgkg 10,910,9 yy–– 2525--4545 kgkg 8,98,9 yy–– 4545 kgkg-- 7,57,5 yy

ASA: ASA: generalisationgeneralisation

0 0 -- 33dd 33d d -- 6w6w 66w w -- 55yy 55 -- 88yy 88 -- 1010yy 1010y y --

ASA 4ASA 4 ASA 2ASA 2 ASA 1ASA 1 ASA 2ASA 2 ASA 3ASA 3 ASA 4ASA 4

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Old patientsOld patientsPhysPhys.. ccharacteristicsharacteristics 11

Heart, circulationHeart, circulation–– Compensation reserve Compensation reserve ↓↓–– Heart muscle disease, valvular insufficiencyHeart muscle disease, valvular insufficiency–– Blood volume, heart minBlood volume, heart min.. volvol.., BP, baroreceptor , BP, baroreceptor

activity activity ↓↓, circulation time , circulation time ↑↑–– VagotoniaVagotonia

RespirationRespiration–– Anatomical dead space, residual volume Anatomical dead space, residual volume ↑↑–– Vital capacity, compliance, OVital capacity, compliance, O2 2 diffusion, COdiffusion, CO22 elim., elim.,

rrespiratespiratoryory freqfreq.., , tidal tidal volume, volume, tidaltidal minmin.. volvol.., , capillary volume, defensive reflexes capillary volume, defensive reflexes ↓↓

Old patientsOld patientsPhysPhys.. ccharacteristics 3haracteristics 3

CNSCNS–– Neurotransmitter synthesis/Neurotransmitter synthesis/degradationdegradation ratioratio ↓↓–– Receptor changesReceptor changes

ThermoregulationThermoregulation ↓↓–– Thermoregulation Thermoregulation ↓↓–– Myelin sheath degeneration, LA effect Myelin sheath degeneration, LA effect ↑↑–– Muscle relaxant effect longer Muscle relaxant effect longer

Vegetative nervous systemVegetative nervous system–– Impulse conduction slows, sensitivity Impulse conduction slows, sensitivity ↑↑–– VagotonyVagotony ↑↑, sensitivity, sensitivity toto catecholaminecatecholaminess ↑↑

Old patientsOld patientsAnesthesiaAnesthesia

PrePre--oxygenation, fluid therapy, warmingoxygenation, fluid therapy, warmingDose reductionDose reduction 5050--70% (!)70% (!)AtropineAtropine (vagotony (vagotony →→ excess tachycardia)excess tachycardia)ACPACP small dose! (BPsmall dose! (BP ↓↓ convusionsconvusions ↑↑))ACPACP small dose! (BP small dose! (BP ↓↓, convusions , convusions ↑↑))Midazolam Midazolam (paradox reaction rare)(paradox reaction rare)OpioidsOpioids (analgesia!, Respiration (analgesia!, Respiration ↓↓))KetamineKetamine (longer duration)(longer duration)PropofolPropofol ((catcat: delayed recovery): delayed recovery)IsofluraneIsofluraneAlphaAlpha22--agonistsagonists: NO: NO! ! (hypotension, bradycardia, (hypotension, bradycardia, arrhythmia, arrhythmia, rrespiration depr., insulin espiration depr., insulin ↓↓, PU), PU)

Old patientsOld patientsAnesthesia of old dogsAnesthesia of old dogs

AtropineAtropine 0.02 mg/0.02 mg/bwkgbwkg imim., iv.., iv.MidazolamMidazolam 0.5 mg/0.5 mg/bwkgbwkg iv.iv. ororACPACP 0.01 mg/0.01 mg/bwkgbwkg imim..PropofolPropofol 2.02.0--5.0 mg/5.0 mg/bwkgbwkg iv.iv.IsofluraneIsoflurane 1 V%1 V%FentanylFentanyl + + propofolpropofol TIVA dose to effectTIVA dose to effect

Old patientsOld patientsAnesthesia of old catsAnesthesia of old cats

AtropineAtropine 0.02 mg/bwkg im.0.02 mg/bwkg im.MidazolamMidazolam 0.5 mg/bwkg iv. or0.5 mg/bwkg iv. orACPACP 0.05 mg/bwkg im.0.05 mg/bwkg im.

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PropofolPropofol 55--7 mg/bwkg iv.7 mg/bwkg iv.IsofluraneIsoflurane 11--1.5 V%1.5 V%KetamineKetamine 0.5 mg/bwkg iv. or0.5 mg/bwkg iv. orfentanylfentanyl 0.003 mg/bwkg iv. (analgesia)0.003 mg/bwkg iv. (analgesia)

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SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndEndooocrinecrinecrine patientspatientspatientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Pregnant patientsPregnant patientsPhys. Phys. ccharacteristics 1haracteristics 1

Body Body mmass ass ratio ratio (fetus(fetus//mother)mother)–– DogDog 16.1%, 16.1%, catcat 13.1 %, 13.1 %, humanhuman 5.7%5.7%

CCirculationirculationH t itH t it ↑↑ h t ih t i ll ↑↑ (( 3030 50%)50%)–– Heart capacity Heart capacity ↑↑, heart min, heart min.. volvol.. ↑↑ (+(+ 3030--50%)50%)

–– Plasma estrogen Plasma estrogen ↑↑, peripheral blood supply , peripheral blood supply ↑↑–– During During partuitionpartuition heart freq. heart freq. ↑↑,,

systolsystolicic BP BP ↑↑ (+(+ 1010--30 mmHg),30 mmHg),ccentralentral vvenousenous ppressureressure ↑↑ (+(+ 44--6 cmH6 cmH22O),O),heart capacity heart capacity ↑↑ (+(+ 1010--25%)25%)

–– Heart reserve capacity Heart reserve capacity ↓↓, compensated heart , compensated heart disease may decompensate disease may decompensate

Pregnant patientsPregnant patientsPhysPhys.. ccharacteristics 2haracteristics 2

RespirationRespiration–– Serum progesterone Serum progesterone ↑↑

Resp. center sensitivity (Resp. center sensitivity (toto higher COhigher CO22 level) level) ↑↑, , hyperventilation respiratory alkalosishyperventilation respiratory alkalosis →→hyperventilation, respiratory alkalosishyperventilation, respiratory alkalosis →→kidneykidneyss compensatcompensatee, pH remains unchanged , pH remains unchanged BBronchialronchial muscle relaxation, lung resistance muscle relaxation, lung resistance ↓↓

–– Resp. volume Resp. volume ↓↓ (diaphragm (diaphragm dislocateddislocated cranialcranial))–– During During partuitionpartuition a a respresp. . frequency frequency ↑↑–– OO22 requirements requirements ↑↑ (+20%)(+20%)–– Hypoxia and Hypoxia and hyhypercpercapniaapnia risk at anesthesia risk at anesthesia

Diaphragm position, Diaphragm position, recumbencyrecumbency, anesthetics , anesthetics

Pregnant patientsPregnant patientsPhysPhys.. ccharacteristics 3haracteristics 3

Fluid homeostasisFluid homeostasis–– Blood volume, plasma volume Blood volume, plasma volume ↑↑ (+40%)(+40%)–– RBCRBC, , HbHb, plasma protein conc. relative , plasma protein conc. relative ↓↓

ExcretionExcretionExcretionExcretion–– GGFRFR ↑↑ (+60%), UREA (+60%), UREA ↓↓, CREA , CREA ↓↓–– „N„Normalormal” UREA and CREA values ” UREA and CREA values meanmean decreaseddecreased

kidney function, NSAID should be avoidedkidney function, NSAID should be avoided–– Anesthetics excreted faster Anesthetics excreted faster

GI systemGI system–– Risk of regurgitation and vomiting Risk of regurgitation and vomiting

Pregnant patientsPregnant patientsPreparationPreparation

Precise body Precise body weightweight measuringmeasuringCCalm, warm, dry environmentalm, warm, dry environmentBlood sampleBlood sample–– BBlood lood countcount, TPP, G, UREA, CREA, ALT, TPP, G, UREA, CREA, ALT

Vein catheterVein catheterPreparation of surgical area while awake Preparation of surgical area while awake Preparation for emergency Preparation for emergency

Pregnant patientsPregnant patientsAnesthesia 1Anesthesia 1

Prevention of vomiting or regurgitation Prevention of vomiting or regurgitation –– MetoclopramideMetoclopramide 0.20.2--0.4 mg/0.4 mg/bwkgbwkg iv., iv., imim..–– CimetidineCimetidine 66--11 mg/11 mg/bwkgbwkg imim..

Infusion therapyInfusion therapyInfusion therapy Infusion therapy –– 2020--60 ml/60 ml/bwkgbwkg/h electrolyte inf./h electrolyte inf.

PreoxygenationPreoxygenationAnticholinergicsAnticholinergics–– GlycopyrrolateGlycopyrrolate preferred preferred

Avoid Avoid –– PhenothiazinesPhenothiazines, barbiturates, al, barbiturates, alphapha22--agonistsagonists

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IntroductionIntroduction–– PropofolPropofol, , ketamineketamine, steroid anesthetics, steroid anesthetics–– RapidRapid intubation, 100% Ointubation, 100% O22, , recumbencyrecumbency

(( il t lil t l d td t ii ))((semilateralsemilateral due to v. cava due to v. cava compessioncompession))

In case of aggressive catIn case of aggressive cat–– KKetamineetamine 55--10 mg/10 mg/bwkgbwkg imim. +. +

benzodiazepinebenzodiazepiness ((0.10.1--0.2 mg/0.2 mg/bwkgbwkg))


Maintenance (balanced)Maintenance (balanced)–– IsofluraneIsoflurane inhalation anesthesiainhalation anesthesia

MAC value MAC value ↓↓ (in cats (in cats --40%)40%)F t lF t l 0 02 /0 02 /b kb k i b di ii b di i 0 10 1

*

–– FentanylFentanyl 0.02 mg/0.02 mg/bwkgbwkg iv. + benzodiazepineiv. + benzodiazepiness 0.10.1--0.5 mg/0.5 mg/bwkgbwkg iv.iv. ((antagonizableantagonizable ataranalgesiaataranalgesia))

–– EEpiduralpidural anesthesia (combination)anesthesia (combination)LLidocaineidocaine 11--2%: 1 ml/5 2%: 1 ml/5 bwkgbwkg or 0.5 ml/10 cmor 0.5 ml/10 cm

SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndEndooocrinecrinecrine patientspatientspatientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Cardiovascular patientsCardiovascular patientsAnomaliesAnomalies

Congenital defects Congenital defects (PDA, PRAA)(PDA, PRAA)CardiomyopathyCardiomyopathy (DCMP, HCMP)(DCMP, HCMP)Heart rhythmsHeart rhythms (arrhythmi(arrhythmiasas))Valvular insufficiencyValvular insufficiency (mitral)(mitral)Pericardial diseasePericardial diseasessHypotension, hypertensionHypotension, hypertensionHypovolaemiaHypovolaemiaAnaemiaAnaemiaHeart wormsHeart worms

Cardiovascular patientsCardiovascular patientsAnesthesia 1Anesthesia 1

PreoxygenationPreoxygenationAtropine, glycopyrrolate Atropine, glycopyrrolate ((→→ tachycardia)tachycardia)Midazolam, ACP Midazolam, ACP ((↓↓))Opioids Opioids ((→→ bradycardia)bradycardia)PropofolPropofolDopamineDopamineNo No kketamine! etamine! ((→→ tachycardia)tachycardia)No inhalants! No inhalants! (neg. inotrop)(neg. inotrop)

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Cardiovascular patientsCardiovascular patientsAnesthesia 2Anesthesia 2

AtropineAtropine dogdog: 0.02: 0.02;; catcat: 0.05 mg/: 0.05 mg/bwkgbwkg imim. . glycopirrolateglycopirrolate dogdog: 0.01: 0.01; ; catcat: 0.02 mg/: 0.02 mg/bwkgbwkg imim..MidazolamMidazolam 0.5 mg/0.5 mg/bwkgbwkg iv. oriv. orACPACP 0 010 01 0 02 mg/0 02 mg/bwkgbwkg imim

*

ACPACP 0.010.01--0.02 mg/0.02 mg/bwkgbwkg imim..PropofolPropofol 2.52.5--4 mg/4 mg/bwkgbwkg iviv..Assisted ventilationAssisted ventilation: : OO22, TV 6, TV 6--8 ml/8 ml/bwkgbwkg,,PEEP 2PEEP 2--4 mmHg4 mmHgDopamine Dopamine 2 (2 (--10) µg/10) µg/bwkgbwkg/min iv. (Ringer inf.)/min iv. (Ringer inf.)PropofolPropofol (50 ml + 5% G inf. 200 ml) and(50 ml + 5% G inf. 200 ml) andfentanylfentanyl (50 ml + Ringer inf. 500 ml) to effect iv.(50 ml + Ringer inf. 500 ml) to effect iv.

SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndEndooocrinecrinecrine patientspatientspatientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Respiratory patientsRespiratory patientsAnomaliesAnomalies

ReceptorsReceptors–– OO22: : glomusglomus caroticumcaroticum;; COCO22: : medullamedulla oblongataoblongata–– TTensionension: lung, chest wall: lung, chest wall–– Touch: defense mechanisms Touch: defense mechanisms

ExtrapulmonaryExtrapulmonary–– Chest movement (rib fracture), Chest movement (rib fracture), diaphragmdiaphragm. h. herniaernia–– PneumoPneumo--, , haemohaemo--, , chylochylo--, hydrothorax, hydrothorax–– Volume Volume extensionsextensions,, megaoesophagusmegaoesophagus, foreign , foreign

bodiesbodies–– Laryngeal paralysisLaryngeal paralysis

IntrapulmonaryIntrapulmonary–– IInflammationnflammation, fibrosis, , fibrosis, oedemaoedema, tumor, , tumor, atelectasiaatelectasia

Respiratory patientsRespiratory patientsAnesthesia 1Anesthesia 1

ParasymParasymppatholyticsatholytics–– Dead space Dead space ↑↑, gland secretion , gland secretion ↓↓, m, mucous ucous m. drym. dry

Phenothiazines Phenothiazines (do(dosissis ↓↓))–– COCO22 thresholdthreshold ↑↑COCO22 thresholdthreshold ↑↑

AlphaAlpha22--agonistagonistss–– Respiration frequency and TV Respiration frequency and TV ↓↓

BenzodiazepinesBenzodiazepines–– COCO22 thresholdthreshold ↑↑

OpioidsOpioids–– Respiration depression (drug and dose dep.)Respiration depression (drug and dose dep.)–– COCO22 thresholdthreshold ↑↑

Respiratory patientsRespiratory patientsAnesthesia 2Anesthesia 2

PhencyclidinesPhencyclidines–– Apneal Apneal rrespiration espiration patternpattern (blood gas param. (blood gas param. ↔↔))–– Bronchosecretion Bronchosecretion ↑↑ (tube suction), salivation (tube suction), salivation ↑↑

PropofolPropofol–– Respiration depression (fast admin, overdose)Respiration depression (fast admin, overdose)

Inhalational anestheticsInhalational anesthetics–– TV TV ↓↓, , rrespiration freq. espiration freq. ↑↑ (doesn’t compensate)(doesn’t compensate)–– COCO22 thresholdthreshold ↑↑

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Respiratory patientsRespiratory patientsIntrapulmonary f. Intrapulmonary f. -- anesthesiaanesthesia

GlycopyrrolateGlycopyrrolate 0.01 mg/0.01 mg/bwkgbwkg iv. oriv. oratropineatropine 0.02 mg/0.02 mg/bwkgbwkg imim..

MidazolamMidazolam 0.5 mg/0.5 mg/bwkgbwkg iv.iv.

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PropofolPropofol 33--5 mg/5 mg/bwkgbwkg iv.iv.

OO22, ventilation , ventilation (mild (mild hyperventhypervent.).)

Fluid therapy Fluid therapy (bicarbonate)(bicarbonate)

PropofolPropofol (50 ml + 5% G inf. 200 ml) and(50 ml + 5% G inf. 200 ml) andfentanylfentanyl (50 ml + Ringer inf. 500 ml) to dose iv.(50 ml + Ringer inf. 500 ml) to dose iv.

SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndEndooocrinecrinecrine patientspatientspatientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Gastrointestinal patientsGastrointestinal patientsAnesthesia 1Anesthesia 1

Foreign Foreign bbodyody rremovalemoval–– ASA dependent anesthesiaASA dependent anesthesia–– Replace fluid deficiency, electrolyte Replace fluid deficiency, electrolyte levellevel correctioncorrection–– CCirculationirculation support: dopamine 0.002support: dopamine 0.002--0.1 0.1

mg/mg/bwkgbwkg/min cont. drip inf. iv. /min cont. drip inf. iv. tto effect o effect –– IInductionnduction: : propofolpropofol 22--4 mg/4 mg/bwkgbwkg iv. iv. tto effect + o effect +

fentanylfentanyl 0.02 mg/0.02 mg/bwkgbwkg iv. iv. –– Maintenance: Maintenance: propofolpropofol 99--15 mg/15 mg/bwkgbwkg/h + /h + fentanylfentanyl

0.02 mg/0.02 mg/bwkgbwkg/h/h–– Postoperative: Postoperative: metoclopramidemetoclopramide, H, H22 blocker, pain blocker, pain

managementmanagement


GGastricastric dilatationdilatation and and volvulusvolvulus (GDV)(GDV)–– DDiaphragmiaphragm dislocationdislocation towards thorax, towards thorax, rrespirationespiration ↓↓–– Venous reflux from abdominal organs Venous reflux from abdominal organs ↓↓, heart min, heart min..

ll ↓↓ h th i BPh th i BP ↓↓ h i id ih i id ivolvol. . ↓↓, arrhythmia, BP , arrhythmia, BP ↓↓, hypoxia, acidosis, hypoxia, acidosis–– Fast fluid therapy (first 30 min):Fast fluid therapy (first 30 min):

10 ml/10 ml/bwkgbwkg HAES 6% + 10 ml/HAES 6% + 10 ml/bwkgbwkg Ringer iv.;Ringer iv.;dopamine 0.005dopamine 0.005--0.01 mg/0.01 mg/bwkgbwkg/min iv./min iv.


GGastricastric dilatationdilatation and and volvulusvolvulus (GDV)(GDV)–– IInductionnduction: : midazolammidazolam 0.5 mg/0.5 mg/bwkgbwkg iv. + iv. + propofolpropofol

33--5 mg/5 mg/bwkgbwkg iv. + iv. + fentanylfentanyl 0.02 mg/0.02 mg/bwkgbwkg iv., fast iv., fast intubation 100% Ointubation 100% O

*

intubation, 100% Ointubation, 100% O22

–– MMaintenanceaintenance: : propofolpropofol + + fentanylfentanyl to effectto effect–– Treatment of Treatment of aarhythmiarhythmia: : lidocainelidocaine 11--2 mg/2 mg/bwkgbwkg iv.iv.

(then 0.04(then 0.04--0.06 mg/0.06 mg/bwkgbwkg/min iv. inf.)/min iv. inf.)+/+/-- procaine 6procaine 6--12 mg/12 mg/bwkgbwkg iv. every 6iv. every 6--8 h8 h

–– In case of shock symptoms consider In case of shock symptoms consider prednisoloneprednisolone–– Postoperative: pain Postoperative: pain managementmanagement

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SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndEndooocrine patientscrine patientscrine patientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Liver patientsLiver patientsAnomaliesAnomalies

CCirculation autoregulationirculation autoregulation ↓↓ ((HMVHMV 25%!)25%!)–– Isoflurane, sevoflurane: vasodilatation (a. hep.)Isoflurane, sevoflurane: vasodilatation (a. hep.)–– Halothane: vasoconstriction (a. hep.)Halothane: vasoconstriction (a. hep.)–– Inhalational anestInhalational anestheticshetics: portal circulation : portal circulation ↓↓pp–– Fasting: autoregulation Fasting: autoregulation ↓↓

Protein metabolism Protein metabolism ↓↓ (TPP 90%, enzymes)(TPP 90%, enzymes)CCarbohydratearbohydrate metabolism metabolism ↓↓ (GNG, storage, GL)(GNG, storage, GL)Metabolism Metabolism ↓↓ (endogen, exogen detox.)(endogen, exogen detox.)EExcretion xcretion ↓↓ (bile)(bile)Immune system Immune system ↓↓Coagulation factors Coagulation factors ↓↓ (I, II, V, VII, IX, X,(I, II, V, VII, IX, X,fibrinolytic activators and inhibitors)fibrinolytic activators and inhibitors)

Liver patientsLiver patientsAnesthesia 1Anesthesia 1

ParasympatholyticsParasympatholytics–– DogDog: excretion mostly unchanged (kidney): excretion mostly unchanged (kidney)–– CatCat:: metabolized by atropinemetabolized by atropine eesterasesterase

PhenothiazinesPhenothiazinesPhenothiazinesPhenothiazines–– GlucGlucuuronicronic conjugation (delayed)conjugation (delayed)

BenzodiazepinesBenzodiazepines–– MidazolamMidazolam ((inacinactivetive metabolites), no diazepammetabolites), no diazepam!!

AlphaAlpha22--agonistsagonists–– PPartialartial biotransformation (vs. unchanged biotransformation (vs. unchanged excrexcr.).)

OpioidsOpioids (f(fentanylentanyl recommendedrecommended))–– GlucoronicGlucoronic conjugation (delayed, rebound!)conjugation (delayed, rebound!)–– Pylorus and Pylorus and OddiOddi sphincter spasm; His sphincter spasm; His ↑↑, , perfperf. . ↓↓


PhencyclidinesPhencyclidines–– DogDog: demethylation, hydrolysis in the liver; : demethylation, hydrolysis in the liver;

hepatoencephalopathihepatoencephalopathicc seizure inductionseizure induction–– CatCat: excreted unchanged in kidney: excreted unchanged in kidney

PropofolPropofol–– Hydroxylation, glucoronic or sulfuric conjugation Hydroxylation, glucoronic or sulfuric conjugation

(delayed inactivation)(delayed inactivation)Inhalational anestInhalational anestheticshetics metabolismmetabolism–– Isoflurane, desflurane, NIsoflurane, desflurane, N22O ~ 0%O ~ 0%–– Sevoflurane, enflurane 8%Sevoflurane, enflurane 8%–– Halothane 50% (don’tHalothane 50% (don’t useuse)!)!–– Methoxyflurane 70% (don’tMethoxyflurane 70% (don’t useuse)!)! (renot(renotoxic oxic

metabolites)metabolites)


Clotting examination, Clotting examination, preoxygenationpreoxygenationAtropine Atropine 0.02 mg/0.02 mg/bwkgbwkg imim..MidazolamMidazolam 0.5 mg/0.5 mg/bwkgbwkg iv.iv.

*

PropofolPropofol 22--5 mg/5 mg/bwkgbwkg iv.iv.VVentilationentilation, hypoxia prevention, hypoxia preventionGGlucoselucose 5% 3 ml/5% 3 ml/bwkgbwkg/h, G /h, G ↓↓ preventionpreventionPlaPlassmaexpmaexp. . 20 ml/20 ml/bwkgbwkg iv. (if Alb. 1.5 g/dl iv. (if Alb. 1.5 g/dl ↓↓))Dopamine Dopamine 2 µg/2 µg/bwkgbwkg/min iv. (if BP /min iv. (if BP ↓↓))IsofluraneIsoflurane max. max. 1% +1% + NN22O O 50% +50% + fentanylfentanyl(best: (best: ramifentanylramifentanyl) to effect) to effect

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SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsEndEndEndooocrinecrinecrine patientspatientspatientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Kidney patientsKidney patientsAnomalies 1Anomalies 1

CCirculationirculation autoregulationautoregulation ((heartheart min. min. volvol.. 25%!)25%!)–– Systemic arterial Systemic arterial meanmean pressurepressure 7070--80 mmHg,80 mmHg,

CVP 0CVP 0--5 cmH5 cmH22O O →→ urine excretionurine excretion 0.50.5--1 ml/1 ml/bwkgbwkg/h /h ↑↑

l d ll d l ↓↓Fluid compartment volume Fluid compartment volume (regulation (regulation ↓↓))–– GlomerulGlomerularar filtrate filtrate →→ prox. prox. ttubulesubules 7/8 7/8 resorptionresorption →→

dist. dist. ttubulesubules ADHADH--dependent dependent resorptionresorption–– OOpioidspioids: ADH : ADH ↑↑, , oliguriaoliguria–– AlphaAlpha22--agonists: ADH agonists: ADH ↓↓, , polyuriapolyuria

Fluid compartment composition Fluid compartment composition (regulation (regulation ↓↓))–– ADH ADH ↑↑: water and Na retention, K loss: water and Na retention, K loss

Kidney patientsKidney patientsAnomalAnomaliesies 22

AcidAcid--bbasease sstatetate (regulation (regulation ↓↓))–– Tubular excretion (HTubular excretion (H++, Na, Na--phosphatephosphate, ammonium , ammonium

salts)salts)

d fd f ↓↓EExcretionxcretion, detoxification , detoxification (endogen, (endogen, exogenexogen) ) ↓↓

ReninRenin, , erythropoetinerythropoetin, vitamin D co, vitamin D connversion, Ca version, Ca and P homeostasis and P homeostasis ↓↓

Kidney patientsKidney patientsAnesthesia 1Anesthesia 1

Prevent Prevent hypovolaemiahypovolaemia, hypotension, hypoxia, acidosis!, hypotension, hypoxia, acidosis!

During anesthesia During anesthesia GFR 100% GFR 100% →→ 40%!40%!

Fluid therapy Fluid therapy (K(K++ level managed)level managed)pypy (( g )g )

DopamineDopamineACP ACP ↓↓ (IR: longer and stronger effect)(IR: longer and stronger effect)

BenzodiazepinesBenzodiazepinesNo No alphaalpha22--agonists!agonists!–– PPerfusionerfusion ↓↓ + insulin + insulin ↓↓, G , G ↑↑ + ADH + ADH ↓↓ →→ PU)PU)

OpioidsOpioids ((ADH ADH ↑↑ →→ oliguriaoliguria))


KetamineKetamine (no(nott in cats!)in cats!)–– PPerfusionerfusion ↑↑, but resistance is , but resistance is ↑↑ →→ GFR GFR ↔↔ ↓↓

PropofolPropofolInhalational Inhalational anestanest..–– Halothane, Halothane, isofluraneisoflurane, , sevofluranesevoflurane, , enfluraneenflurane, N, N22O:O:

heart minheart min.. volvol.. ↓↓, perfusion , perfusion ↓↓, ADH , ADH ↓↓–– DesfluraneDesflurane recommendedrecommended

FLUTDFLUTD–– Dehydration, KDehydration, K++ ↑↑, acidosis, P , acidosis, P ↑↑, hypothermia, hypothermia–– KK++ ↑↑ →→ bradycardiabradycardia (1(1--2 2 mmolmmol//bwkgbwkg NaNa--bicarbbicarb. . iv.)iv.)

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AtropineAtropine 0.02 mg/0.02 mg/bwkgbwkg imim..

DopamineDopamine 0.50.5--2 µg/2 µg/bwkgbwkg/min iv./min iv.

MidazolamMidazolam 0.5 mg/0.5 mg/bwkgbwkg iv.iv.

*

g/g/ gg

PropofolPropofol 33--5 mg/5 mg/bwkgbwkg iv.iv.

VentilationVentilationPropofolPropofol (50 ml + 5% G inf. 200 ml) and(50 ml + 5% G inf. 200 ml) andfentanylfentanyl (50 ml + Ringer inf. 500 ml) to effect iv.(50 ml + Ringer inf. 500 ml) to effect iv.

IIsofluranesoflurane 0.80.8--1 V%1 V%

Fluid therapy Fluid therapy postoppostop. . ffor 2 days!or 2 days!

SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndoocrinecrine patientspatientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Diabetes mellitusDiabetes mellitusPreparation 1Preparation 1

Constantly elevated blood glucoseConstantly elevated blood glucose--levellevel–– 7.5 mmol/l 7.5 mmol/l ↑↑

IDDMIDDMMiddl d d ld f l dMiddl d d ld f l d–– Middle aged and old female dogs Middle aged and old female dogs (poodle, dachs(poodle, dachshhund, spitz, terriers, spaniels)und, spitz, terriers, spaniels)

NIDDMNIDDM–– Old catsOld cats


Detailed patient examDetailed patient exam–– Blood (blood Blood (blood countcount, fasting G, Ht, ALT, AST, AP, , fasting G, Ht, ALT, AST, AP,

Urea, Urea, CreaCrea, , ketoneketone bodies, serumbodies, serum--electrolyteelectrolytess, , bloodblood gasgas values)values)gg ))

–– Urine (density, G, Urine (density, G, ketoneketone bodies)bodies)–– CConsequencesonsequences: fatty liver : fatty liver →→ hepatomegalyhepatomegaly, ,

cirrhosis, cirrhosis, urosepsisurosepsis, pr, prererenalenal uraemiauraemia, etc, etcMetabolic anomaliesMetabolic anomalies ((praeoppraeop. correction. correction!!))–– GG ↑↑,, dehydration, blood gasdehydration, blood gas values (Kvalues (K++), serum), serum--

electrolyteelectrolytess


IInsulinnsulin (goal: G 11(goal: G 11--14 14 mmolmmol/l /l ↓↓))–– IIm.: 0.1 IU/m.: 0.1 IU/bwkgbwkg/h, then 0.5 IU//h, then 0.5 IU/bwkgbwkg every 6every 6--8 8 hh–– IIv.: 10v.: 10--15 15 IUIU /1000 ml /1000 ml salsolsalsol or dextrose 5%, 0.05or dextrose 5%, 0.05--

0 1 IU/0 1 IU/bwkgbwkg/h/h0.1 IU/0.1 IU/bwkgbwkg/h/hResistance Resistance ↓↓–– PreopPreop. AB + sterility! (. AB + sterility! (veinvein cathetercatheter sterilitysterility!!))

PerioperativePerioperative stressstress diabetogendiabetogen–– EpinephrineEpinephrine, nor, norepinephrineepinephrine, , cortisolcortisol, STH, , STH,

glucagonglucagon ↑↑

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Diabetes mellitusDiabetes mellitusAnesthesia 1Anesthesia 1

RecommendedRecommended–– SShorthort durationduration oror antagonizableantagonizable agentsagents–– PPremedicationremedication: diazepam + : diazepam + butorphanolbutorphanol

induction and maintenance:induction and maintenance: propofolpropofol oror isofluraneisoflurane–– induction and maintenance: induction and maintenance: propofolpropofol or or isofluraneisofluraneAvoidAvoid–– XylazineXylazine (G (G ↑↑) ) –– GlucocorticoidsGlucocorticoids (anti(anti--insulin insulin effeff.., , immunsupprimmunsuppr.).)–– Hypoxia (Hypoxia (catecholaminescatecholamines, G , G ↑↑))


Perioperative GPerioperative G--controlcontrol--protocolsprotocols–– Tight control: continuous insulin and glucoseTight control: continuous insulin and glucose--

infusion (continuous monitoring, small variance)infusion (continuous monitoring, small variance)L t l f d l i liL t l f d l i li–– Loose control: no food, no glucose, no insulin on Loose control: no food, no glucose, no insulin on day of surgery (progressive G day of surgery (progressive G ↑↑))


CompromiseCompromise–– Perform usual routine until midnight of day Perform usual routine until midnight of day

before surgery before surgery –– Fasting after midnightFasting after midnight anestanest in early morningin early morning

*

Fasting after midnight, Fasting after midnight, anestanest. in early morning . in early morning –– G measuring G measuring 1 h1 h before; then every hour before; then every hour –– In the morning 50% of normal insulinIn the morning 50% of normal insulin

+ 10 ml/+ 10 ml/bwkgbwkg/h dextrose 5% inf. /h dextrose 5% inf. –– If G If G ↑↑: 0.25: 0.25--0.5 IU/0.5 IU/bwkgbwkg imim. insulin. insulin–– If G If G ↓↓: dextrose intake : dextrose intake ↑↑

PostopPostop. . ffastingasting–– Minimal time (gen. 0Minimal time (gen. 0--3 3 dayday))–– IIv. dextrose + v. dextrose + imim. . iinsulinnsulin every 6 hevery 6 h

SubjectsSubjects


Cushing SyndromeCushing SyndromePreparation 1Preparation 1

HyperadrenocortiHyperadrenocorticicismsm (cortisol(cortisol ↑↑))–– HHypophysis (85ypophysis (85--95%) 95%) →→ hypophysectomhypophysectomyy–– UnilatUnilat.. adrenal gland adrenal gland tumor (5tumor (5--15%) 15%) →→

adrenalectomadrenalectomyyadrenalectomadrenalectomyy–– IatrogenIatrogen

DispositionDisposition–– Middle aged and old small body dogs (beagle, Middle aged and old small body dogs (beagle,

miniature schnauzer, boxer)miniature schnauzer, boxer)

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Cushing SyndromeCushing SyndromePreparation 2Preparation 2

Multisystemic changes Multisystemic changes = risk factors= risk factorsCCirculation examirculation exam (physical, RTG, ECG, US) (physical, RTG, ECG, US) –– Fluid retention, hypertension, valvular Fluid retention, hypertension, valvular

insufficiency left ventrinsufficiency left ventricularicular hhypertrophy chronicypertrophy chronicinsufficiency, left ventrinsufficiency, left ventricularicular hhypertrophy, chronic ypertrophy, chronic heart failure heart failure

Respiration examRespiration exam ((rrespiration, blood gas)espiration, blood gas)–– WWeak respiratory muscles, thoraeak respiratory muscles, thoraciccic and abd. and abd. ffat at

depot, hepatomegaly, decreased diaphragm depot, hepatomegaly, decreased diaphragm mmovementsovements

–– Consider Consider IPPVIPPV

Cushing syndromeCushing syndromePreparation 3Preparation 3

Increased Increased mineralocorticoidmineralocorticoid--levellevel–– NaNa++-- and water retention (and water retention (↑↑ levellevel))–– IIncreasedncreased KK++-- and Hand H++--excretion (excretion (↓↓ levellevel))

Following Following mitothanemitothane ththerapyerapy(50 mg/(50 mg/bwkgbwkg//dayday o,po,p--DDD, DDD, LysodrenLysodren for 25 days)for 25 days)may be may be mineralcortmineralcort. . ddefeficiencyiciency–– HypovolaemiaHypovolaemia, , hyperkalaemiahyperkalaemia, acidosis, acidosis–– Fluid replacement, balanced electrolytes, Fluid replacement, balanced electrolytes,

glucocorticoidglucocorticoid--, , mineralocorticoidmineralocorticoid--replrepl. iv.. iv.

Cushing syndromeCushing syndromePPreparation 4reparation 4

CushingCushing--syndrome syndrome →→ diabetes mellitusdiabetes mellitus–– Cortisol Cortisol levellevel ↑↑ →→ insulin reqinsulin requirementuirement ↑↑

Cortisol Cortisol levellevel ↓↓ →→ relative hyperinsulinaemiarelative hyperinsulinaemiaP ti it th thP ti it th th–– Preoperative mitothane therapyPreoperative mitothane therapy

–– Adrenocortical inhibitors (metyrapone, Adrenocortical inhibitors (metyrapone, aminoglutethimide)aminoglutethimide)

–– AAdrenocorticaldrenocortical--tumor resectiontumor resection

Cushing syndromeCushing syndromeAnesthesia 1Anesthesia 1

AnestheticAnesthetic--selectionselection–– Endocrine disease Endocrine disease limits minimallylimits minimally

AAvoid:void: etomidate, metomidateetomidate, metomidate–– During unilateral adrenalDuring unilateral adrenal--tumortumor--resection resection

suppresses contralateral function as well suppresses contralateral function as well

Perioperative stabilityPerioperative stability–– FFluidluid--, electrolye, electrolye--, , acidacid--base base homeostasis and Ghomeostasis and G–– IPPV: IPPV: resp. min. vol.resp. min. vol. 150 ml/bwkg/min 150 ml/bwkg/min ↑↑, PaCO, PaCO22

60 mmHg 60 mmHg ↓↓

Cushing syndromeCushing syndromeAnesthesia 2Anesthesia 2

SubstitSubstituution therapy after radical surgery tion therapy after radical surgery –– Until stabilization after unilateral adrenalectomy Until stabilization after unilateral adrenalectomy

(remaining adrenal gland maintains function)(remaining adrenal gland maintains function)U til th d f i l’ lif ft bil t lU til th d f i l’ lif ft bil t l

*

–– Until the end of animal’s life after bilateral Until the end of animal’s life after bilateral adrenalectomy and hypophysectomy adrenalectomy and hypophysectomy

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SubjectsSubjects


HypothyreosisHypothyreosisPreparation 1Preparation 1

Most common endocrinopathy in dogs Most common endocrinopathy in dogs –– Middle aged and old dogsMiddle aged and old dogs

(dobermann, boxer, retriever, beagle, schnauzer)(dobermann, boxer, retriever, beagle, schnauzer)95% i idi thi t i95% i idi thi t i–– 95% primary idiopathic or autoimmune 95% primary idiopathic or autoimmune


Anesthesiological aspect:Anesthesiological aspect:–– Metabolic rate Metabolic rate ↓↓ →→ drug metabolism drug metabolism ↓↓

aanestheticnesthetic--sensitivity sensitivity ↑↑M di t tilitM di t tilit ↓↓ b d dib d di–– Myocardium contractility Myocardium contractility ↓↓, bradycardia, bradycardia

–– Anaemia (Anaemia (consider consider transfusion)transfusion)–– OObesity, decreased diaphragm movementbesity, decreased diaphragm movement–– Thermoregulation Thermoregulation disturbancesdisturbances (hypothermia)(hypothermia)


PrePre--treatment for elective surgery:treatment for elective surgery:–– LL--thyroxine 20 µg/bwkg/day at least 2 weeks po. thyroxine 20 µg/bwkg/day at least 2 weeks po.

(reach the (reach the normal „normal „euthyroid riskseuthyroid risks””))Fast filling for emergency surgeryFast filling for emergency surgeryFast filling for emergency surgeryFast filling for emergency surgery–– LL--thyroxine 1x 20thyroxine 1x 20--40 µg/bwkg iv. 40 µg/bwkg iv.

(or L(or L--triidothyronine 4x 4triidothyronine 4x 4--6 µg/bwkg po. )6 µg/bwkg po. )–– ThyreotoxiThyreotoxiccosisosis may happenmay happen

AnestheticAnesthetic selectionselection–– In small part In small part metabolizable drugs metabolizable drugs –– Dose Dose ↓↓

HypothyreosisHypothyreosisAnesthesia 1Anesthesia 1

PremedicationPremedication (not always)(not always)–– 0.050.05--0.1 mg/bwkg butorphanol im. 0.1 mg/bwkg butorphanol im.

(sedation, potentiation, analgetic)(sedation, potentiation, analgetic)BB d did di 0 020 02 0 06 /b k t i i0 06 /b k t i i–– BBradycardiaradycardia:: 0.020.02--0.06 mg/bwkg atropine im.0.06 mg/bwkg atropine im.

Induction and maintenanceInduction and maintenance–– Propofol to effect iv.Propofol to effect iv.–– IIsoflurane (even during myocardial depression)soflurane (even during myocardial depression)–– Halothane (milder peripheral vasodilation than Halothane (milder peripheral vasodilation than

isoflurane isoflurane →→ BP BP ↓↓, temp , temp ↓↓))

HypothyreosisHypothyreosisAnesthesia 2Anesthesia 2

AvoidAvoid–– Respiration depressing drugs (Respiration depressing drugs (decreaseddecreased

diaphragm movement)diaphragm movement)ACP d th h thi i (ACP d th h thi i (ll ff tff t

*

–– ACP and other phenothiazines (ACP and other phenothiazines (longerlonger effect, effect, hypotermia, hypotension)hypotermia, hypotension)

MonitoringMonitoring–– RespirationRespiration-- and blood gasand blood gas--parameters (IPPV)parameters (IPPV)–– Fluid homeostasisFluid homeostasis–– TTemperature (warm inf., heating pad)emperature (warm inf., heating pad)

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SubjectsSubjects


HyperthyreosisHyperthyreosisPreparation 1Preparation 1

Hypermetabolic state Hypermetabolic state →→ multisyst. consmultisyst. consequenciesequenciesMiddle aged and old animalsMiddle aged and old animals–– CCats (adenoma), dogs rarely (carcinoma)ats (adenoma), dogs rarely (carcinoma)

MM t b li tt b li t ↑↑MMetabolic rate etabolic rate ↑↑–– OO22-- and Gand G--requirement requirement ↑↑, drug, drug--metabolism metabolism ↑↑

Cardiac consequencesCardiac consequences–– TachycardiaTachycardia–– Myocardial sensitivity to hypoxia, dysrhythmiaMyocardial sensitivity to hypoxia, dysrhythmia–– CMP (HCMP), chronic heart failure (15%)CMP (HCMP), chronic heart failure (15%)


Detailed patient examDetailed patient exam–– Auscultation, RTG, ECG, USAuscultation, RTG, ECG, US–– Laboratory: ALT, AST, APLaboratory: ALT, AST, AP

GGoaloal–– RReach each a a euthyreoid stateeuthyreoid state


MethimazoleMethimazole–– 1 (1 (--1.5) mg/bwkg 3x daily, for 2 weeks 1.5) mg/bwkg 3x daily, for 2 weeks –– 22--3 weeks euthyreoid state: symptoms normalize3 weeks euthyreoid state: symptoms normalize–– Stop in case of aStop in case of agranulocytosis, thrombocytopeniagranulocytosis, thrombocytopenia

PropranololPropranolol–– 0.50.5--1 mg/bwkg 3x daily, for 71 mg/bwkg 3x daily, for 7--14 days14 days–– ßß--blobloccker (tachyarrhythmias, ker (tachyarrhythmias, hyperhypersensitivity sensitivity ↓↓))–– Carefully in chronic heart failure cases (negCarefully in chronic heart failure cases (neg..

inotrope)inotrope)

HyperthyreosisHyperthyreosisAnesthesia 1Anesthesia 1

Most general protocols are safeMost general protocols are safe–– After 2 weeks maintaining a euthyreoid stateAfter 2 weeks maintaining a euthyreoid state

In untreated animals avoid In untreated animals avoid –– Ketamine, tiletamine (Ketamine, tiletamine (→→ catecholaminecatecholamine level level ↑↑))–– AAtropine (tropine (→→ vagal tone decreases)vagal tone decreases)–– Xylazine, halothane (Xylazine, halothane (→→ myocardimyocardialal sensitivity)sensitivity)

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PremedicationPremedication–– 0.050.05--1 mg/bwkg ACP im. (stress 1 mg/bwkg ACP im. (stress ↓↓, dysrhythmia , dysrhythmia ↓↓, ,

ßß--blocker blocker →→ BP BP ↓↓))O i id ( di l OO i id ( di l O d dd d ↓↓ b d di )b d di )–– Opioids (myocardial OOpioids (myocardial O22--demand demand ↓↓, bradycardia), bradycardia)

InductionInduction–– IIv.: propofol, thiobarbituate, alphaxalonev.: propofol, thiobarbituate, alphaxalone

and alphadolone (dysrhythmias and alphadolone (dysrhythmias ↓↓))–– Inhalational: stress in awake patient Inhalational: stress in awake patient →→

catecholamine catecholamine ↑↑


IntubationIntubation:: smaller tubesmaller tube oror tracheotomytracheotomyMaintenanceMaintenance–– IIsofluranesoflurane (easy regulation, (easy regulation, don’tdon’t causescauses heart heart

musclemuscle sensitisensitizationzation minimal myocardialminimal myocardialmuscle muscle sensitisensitizationzation, minimal myocardial , minimal myocardial depression )depression )

MonitoringMonitoring–– ECG: ventricular ECG: ventricular dysrhythmiasdysrhythmias

0.010.01--0.05 mg/0.05 mg/bwkgbwkg iv. iv. propranololpropranolol,,0.10.1--1 mg/1 mg/bwkgbwkg iv. iv. lidocainelidocaine

–– Body Body ttemperatureemperature–– Oxygen consumption Oxygen consumption ↑↑ (sensitive to hypoxia)(sensitive to hypoxia)


Complications of bilat. thyreoidectomComplications of bilat. thyreoidectomyy–– Iatrogen hypoparathyreoidism Iatrogen hypoparathyreoidism may be:may be:

blood exam.blood exam. over 3 days: Ca over 3 days: Ca ↓↓ (convulsions) (convulsions) →→Ca and D vitCa and D vit

*

Ca and D vit.Ca and D vit.

Total Total thyreoidectomythyreoidectomy–– Total hormonTotal hormonalal replacement after 24replacement after 24--48 h48 h

SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndEndooocrinecrinecrine patientspatientspatientsSeptic patientsSeptic patientsTrauma patientsTrauma patientsTrauma patients

Septic patientsSeptic patientsAnomalies 1Anomalies 1

SIRSSIRS (Systemic Inflammatory Response Syndrome(Systemic Inflammatory Response Syndrome of of noninfectious originnoninfectious origin))–– Trauma, Trauma, sterilsteril inflammation, burns etinflammation, burns etcc..

SepsisSepsis ((likelike SIRS SIRS butbut infections origininfections origin))–– PyometraPyometra, , pyothoraxpyothorax, prostate, prostate--, liver, liver--, kidney, kidney--

abcessabcess, mastitis, wound inf., GI perforation, , mastitis, wound inf., GI perforation, --arrodationarrodation etc.etc.

MODSMODS (Multiple Organ Dysfunction Syndrome: (Multiple Organ Dysfunction Syndrome: consequence of SIRS or sepsisconsequence of SIRS or sepsis))–– Organ systems affected in following order:Organ systems affected in following order:

dogdog: GI, liver, kidney, lung: GI, liver, kidney, lung; ; catcat: lung : lung

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Signs of septic stateSigns of septic state–– Core body temperature Core body temperature

< 38ºC: hypovolaemic shock, bacteriaemia< 38ºC: hypovolaemic shock, bacteriaemia> 40ºC: bacteriaemia> 40ºC: bacteriaemia> 40ºC: bacteriaemia> 40ºC: bacteriaemia

–– PeripheralPeripheral body temp. min. 6ºC body temp. min. 6ºC ↓↓–– Pulse freq. Pulse freq. ↑↑ (150(150--200/min)200/min)–– Respiration freq. Respiration freq. ↑↑

(metabolic acidosis, thromboembolism, respiratory (metabolic acidosis, thromboembolism, respiratory insufficiency)insufficiency)


Signs of septic state Signs of septic state –– CRT > 2 secCRT > 2 sec–– MucMucousous mmembrembr..: pale, anemic, gray: pale, anemic, gray

Systolic arterial pressure < 90 mmHgSystolic arterial pressure < 90 mmHg–– Systolic arterial pressure < 90 mmHgSystolic arterial pressure < 90 mmHg–– Central venous pressure Central venous pressure

< 1< 1--2 cmH2 cmH22O: O: hypovolaemiahypovolaemia> 15 cmH> 15 cmH22O: right sided heart failure, inf. O: right sided heart failure, inf. ↑↑

–– Urine filtration < 0.5 ml/Urine filtration < 0.5 ml/bwkgbwkg/h/h–– Ht < 20%: bleeding, Ht < 20%: bleeding, overinfusionoverinfusion

Ht > 50%: fluid lossHt > 50%: fluid loss–– G < G < 3.9 mg/dl (3.9 mg/dl (7070 mg/dlmg/dl)): sepsis: sepsis

Septic patientsSeptic patientsPreparationPreparation

Eliminate infection source Eliminate infection source –– DrainDrain–– Antibiosis (based on hemoculture)Antibiosis (based on hemoculture)

CCirculation supportirculation supportCCirculation supportirculation support–– Volume support, acidosis correctionVolume support, acidosis correction–– Increase of systemic central pressure Increase of systemic central pressure –– Optimize pressure of right and left ventricle Optimize pressure of right and left ventricle –– Optimize heart indexOptimize heart index

Support tissue perfusionSupport tissue perfusion–– PreoxygenationPreoxygenation

Septic patientsSeptic patientsAnesthesiaAnesthesia

Fast inductionFast induction–– EtomidateEtomidate 0.50.5--1.5 mg/1.5 mg/bwkgbwkg iviv.. oror

midazolammidazolam + + ketamineketamineII t b tit b ti

*

–– IIntubationntubation

Maintenance (balance)Maintenance (balance)–– FentanylFentanyl 0.01 mg/0.01 mg/bwkgbwkg/20 min iv./20 min iv.–– VecuroniumVecuronium 0.080.08--0.1 mg/0.1 mg/bwkgbwkg/20 min iv./20 min iv.–– Can be increased with inhalational anesthetics Can be increased with inhalational anesthetics

((isofluraneisoflurane, , sevofluranesevoflurane))–– AArtificialrtificial ventilation! ventilation!

SubjectsSubjects

Young patientsYoung patientsYoung patientsOld patientsOld patientsOld patientsPregnant patientsPregnant patientsPregnant patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsCardiovascular patientsRespiratory patientsRespiratory patientsRespiratory patientsGI patientsGI patientsGI patientsLiver patientsLiver patientsLiver patientsKidney patientsKidney patientsKidney patientsEndEndEndooocrinecrinecrine patientspatientspatientsSeptic patientsSeptic patientsSeptic patientsTrauma patientsTrauma patients

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Trauma patientsTrauma patientsAnomalies 1Anomalies 1

Common changes Common changes –– Thoracic changes in 70% of cases (oedema, thoracic Thoracic changes in 70% of cases (oedema, thoracic

bleeding, PTX, diaphragmatic hernia, rib fracture)bleeding, PTX, diaphragmatic hernia, rib fracture)–– SSpleenpleen-- liver ruptureliver rupture urinaryurinary bladder rupturebladder ruptureSSpleenpleen , liver rupture, , liver rupture, urinary urinary bladder rupturebladder rupture–– CNS injuriesCNS injuries

Emergency cases Emergency cases –– Processes constricting upper respiratory tract Processes constricting upper respiratory tract –– Open chest wounds, tension PTXOpen chest wounds, tension PTX–– Open abdomen, eventration of abdominal organs Open abdomen, eventration of abdominal organs –– Life threatening bleeding Life threatening bleeding

Trauma patientsTrauma patientsPreparationPreparation

Stabilization Stabilization ((rrespirationespiration, circulation, homeostasis), circulation, homeostasis)

AnalgesiaAnalgesia–– BButorphanolutorphanol 0.4 mg/0.4 mg/bwkgbwkg imim..–– CCarprofenarprofen 4 mg/4 mg/bwkgbwkg iv.iv.–– MMeloxicameloxicam in dog: 0.2 mg/in dog: 0.2 mg/bwkgbwkg iv.iv.

((((in cat 0.3 mg/in cat 0.3 mg/bwkgbwkg iv.iv.))))PremedicationPremedication–– MMidazolamidazolam 0.5 mg/0.5 mg/bwkgbwkg imim., iv.., iv. oror diazepam 0.5 diazepam 0.5

mg/mg/bwkgbwkg iv. + iv. + butorphanolbutorphanol 0.10.1--0.4 mg/0.4 mg/bwgbwg imim., iv.., iv.

Trauma patientsTrauma patientsAnesthesiaAnesthesia

InductionInduction–– PPropofolropofol 11--5 (5 (--10) mg/10) mg/bwkgbwkg iv. iv. tto effect o effect

MMaintenanceaintenanceII flfl flfl 22 3 V% O3 V% O

*

–– IIsofluranesoflurane, , sevofluranesevoflurane: 2: 2--3 V% + O3 V% + O2 2 (contraindicated in CNS, increases intracranial (contraindicated in CNS, increases intracranial pressure)pressure)

–– PPropofolropofol 15 mg/kg/h (Dextrose 5% inf.)15 mg/kg/h (Dextrose 5% inf.)++ fentanylfentanyl 0.02 mg/kg/h iv. (Ringer0.02 mg/kg/h iv. (Ringer--lactate inf.)lactate inf.)

–– MMidazolamidazolam 0.5 mg/0.5 mg/bwkgbwkg imim., iv.., iv.+ + fentanylfentanyl 0.02 mg/0.02 mg/bwkgbwkg imim., iv.., iv.

ANGOL 4.1.ppt [Kompatibilitási mód] - kisallatsebeszet.hu · Anesthesia of risk patients inin...

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