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Anesthesiology of dog and cat

General surgery and anesthesiology

4th study year FVM

Fundamentals of„safe“ anesthesia

1. Venous access

2. Endotracheal intubation

3. Oxygenation

4. Artificial lung ventilation

5. Knowledge and possibility of CPCR

Anesthesia of DOG

• Monoanesthesia

– Propofol i.v.

– Inhalation anesthesia (Iso, Sevo, Des)

• Examination

• Painless procedures only

• 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

• Anesthesia induction

– Intravenous

• Propofol, Thiopental, Thiopental, Etomidate, Alfaxalon

• Diazepam/Ketamin

– Intramuscularly

• Ketamin, Zolazepam/Tiletamin, Alfaxalon

– Inhalation (by mask) – Iso, Sevo, Des

Anesthesia of DOG

• 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

Anesthesia of CAT

• Monoanesthesia

– Ketamin, Zolazepam/Tiletamine i.m.

– Propofol, Alfaxalon i.v.

– Inhalation anesthesia (Iso, Sevo, Des)

• Examination

• Painless procedures only

– 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

• Anesthesia induction

– Intravenously

• Propofol, Ketamin, Alfaxalon

– Intramuscularly

• Ketamin, Zolazepam/Tiletamine, Alfaxalon

– Inhalation (by mask, chamber)

• Iso, Sevo, Des

Anesthesia of 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

Patient with

cardiovasculardisease

4th study year FVM

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

Anesthetics

• Influences

– Autonomic functions

– Vascular tone

– Heart rate

– Myocardial contractility

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

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 ↑

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

Goals of anesthesia

• Stable HR

– Catecholamine, vagal tone

– Anesthesia depth, level of analgesia

• Stable MAP

– Fluid therapy

• Sufficient oxygenation

– Hemoglobin, ventilation

– Anemia, normoxia

• Preparation of drugs, anesthetics, equipment, …

– Atropine, Epinephrine, Lidocaine

• Continual monitoring

• Pre/oxygenation

• Sedation

– Sufficient reduction of stress

• Adequate analgesia

• Smooth induction

Anesthetic protocol

• Balanced anesthesia

• Constant, adequate depth of anesthesia

• Sufficient analgesia

• Normoxia – oxygenation

• Ventilation – minimal PIP/PEEP

• Adequate monitoring

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

• Intra-cardiac pressures

Cardiologic patient

• 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

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

Stenosis of a. pumonalis

• Insufficiency of v. tricuspidalis – RA hypertrophy –RV hypertrophy

• Anesthesiaa

– Keep venous return, preload

– Maintain contractility – HR

– Maintain PVR (IPPV/PEEP)

l of C

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

l of C

Valvular defects

• Bradycardia, hypotension, lung edema

• Accurate dosing of fluids

• Anesthesia

– Reduce bradycardia

– Slight tachycardia

– Maintain C.O.

– Keep (decrease?) SVR, PVR

• 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

• 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

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

Systemic hypertension

• Stress – sympatric stimulation – myocardial hypoxia – arrhythmias

• Anestezia

– Stable HR, SV

– Stable MAP

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?)

• (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.

• 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.

Patient with

respiratorydisease

4th study year FVM

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

Healthy lungs Pathology

FiO2 21 % (0,21) 21 % (0,21)

PaO2 110 mmHg 50 mmHg

PaO2 / FiO2 524 238

PaO2 / FiO2

(normal)

(abnormal)

PaO2 / FiO2 ratio

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)

Bronchial effects

• Bronchodilatation

– Atropine, Ketamin, (Propofol)

– Ketamin/propofol ("Ketofol", 0.5/0.5 doses in one syringe)

• Bronchoconstriction

– Thiopental

• Antitussic effect

– Butorphanol, Codeine

Anesthetic technique

• Preoxygenation (3 minutes)

• Induction

– Fast – i.v. + ETR

– Benzodiazepines + opioids

+ Propofol, Alfaxalon

• Adequate ETR

• TIVA

• Precise checking of ventilation (IPPV/PEEP)

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

Bronchoscopy

• Pre/oxygenation

• Feline asthma – Albuterol

• Adapter for bronchoscopy

• Larmasks

• Pre/oxygenation

• Albuterol

• Midazolam

Butorphanol

Ketamin – bronchodilation

• Stimulation of pharynx – spasm

– Lidokain local

Feline asthma

Contusion, pneumonia, bullae, …

• Pre/oxygenation

• Risk of bleeding, rupture

• Spontaneous breathing

• IPPV/PEEP

– fR 8–10 breaths/min

– PIP ˂ 10 cmH2O

Patient withhepaticdisease

4th study year FVM

Glucose

Detoxication

Proteins Lipids

CoagulationProduction

regulation

Blood plasma protein binding

• High (> 80%)

– Propofol, Diazepam

• Medium (50-80%)

– Thiopental

• Low (< 50 %)

– Ketamine, Morphine

• Change of anesthetic effectiveness

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

• 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.

• High risk patients

• Liver hypoplasia

– Hepatoencephalopathy

– Hypoglycemia

– Blood coagulation impaired

– Hypoprotemia

• Surgery

– Serious changes of blood pressure

Portosystemic shunt (PSS) I.

• Postoperative care

– Normothermia

– Normoglycemia

– Normotension

– Control of seizures

– Normoproteinemia

– Oxygenation

Portosystemic shunt (PSS) II.

Liver biopsy

• Sedation, decrease of fR

• Hemostatic examination

• (Vitamin K?)

• Premedication

– Opioids (Fentanyl derivates, Pethidine)

• Anestezia

– Propofol, Alfaxalon

Abnormalities of biliary tract

• In small animals rare

• Oddi´s sphincter– increases pressure in biliary tract– Opioids– Morphine – Pethidine, Fentanyl –

Butorphanol – Buprenorphine, Nalbuphine

Anesthesia for hepatopathy I.

• Hemostazeology

• Short acting anesthetics

• Hydratation

• Normoglycemia, normoproteinemia

• Normotension

• Eukapnia

• Control of seizure

• Risk of thromboembolia

• Premedication

– Opioids (Morphine unsuitable)

– (Atropine?)

• Induction

– Mask? – cooperating patients only

– Propofol, Etomidate, Alfaxalone

• Maintenance

– Iso, Sevo, Des

– (Atracurium?)

Anesthesia for hepatopathy II.

Patient with

urologicdiasease

4th study year FVM

Pathophysiology I.

• Autoregulation of glomerular filtration

– MAP 80–180 mmHg

– Hypovolemia – vasoconstriction

• Fenothiazines

• Up to 50% lower GF

• Correction (> 4 hours)

• Anesthesia

– Autoregulation impaired

• 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.

Nephrotoxins

• Aminoglycoside antibiotics

• Amphotericin B

• Hemoglobin, bilirubin, myoglobin

• Fluoride ions

• X-ray contrast media

• Oxalates

• Metoxyflurane

• Non-steroidal anti-inflammatory agents

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

• Without abnormalities

• Abnormalities

– Hyperkalemia, hyperphosphatemia, hypocalcemia, hyponatremia

– Acidosis

– Hypovolemia

• Emergency states

– Urinary tract obstructions

– Urinary bladder rupture

Urologic patient II.

Influence of anesthetics

Kidney perfusion GFR

Etomidate +++ +++

Thiopental +++ ++↓

Ketamin ↑↑ ++↓

Iso, Sevo ↓ ↓↓

Nephropaties

• Drugs effect prolonged

– With active metabolites

• Morphine, Ketamine, Diazepam

– Primarily excreted by kidneys

• Pankuronium, Ketamine

Patient with

neurologicdisease

4th study year FVM

• ICP = 0-10 mmHg

CPP = MAP – ICP

• MAP = 70-80 mmHg

• PaCO2 = 35-40 mmHg

• PaO2 = 90-100 mmHg

Patophysiology

Normotension and normocapnia

Seymour Ch, Duke Novakowski T 2007: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia

Regulation of ICP

• Patient positioning

• Stabilization of MAP, CVP

• Normocapnia (IPPV), oxygenation

• Sedation

• Lidocaine

• Furosemide

• Mannitol

Influence of anesthetics on ICP

Ketamin

Acepromazine

Opioids

Dex/medetomidine

Benzodiazepines

Isoflurane, Sevoflurane

Propofol, Thiopental

Anesthesia

– Opioids (Morphine?)

– Alpha-2 agonists (Xylazine?), Benzodiazepines

• Induction and maintenance

– Propofol (CRI)

– Iso, Sevo, Des

– Induction by mask – unsuitable (excitation)

Analgesia

• Opioids

• Alpha-2 agonists

• NSAIDs, steroids

• Ketamine – low doses, CRI

• Lidocaine – CRI

• Gabapentin (anticonvulsant)

• Amitriptiline (tricyclic antidepressives)

Patient with epilepsy

• Acepromazine? (Tobias a kol. 2006)

• Opioids

• Low doses of alpha-2 agonists

• Benzodiazepines (in combination)

• Propofol, Thiopental

• Ketamine unsuitable

Patient with

gastrointestinaldisease

4th study year FVM

Gastrointestinal abnormalities

• Abnormalities

– Electrolyte, acid-base

– Dehydratation, hypovolemia

– Malabsorption, hypoproteinemia

• Emergency cases

– Volvulus, perforation, …

• Pancreas

– Changes of glucose metabolism

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

Abnormalities of oral cavity

• Toot and periodontal disease

• Pathology of salivary glands

• Pathology of pharynx

– ETR intubation

– Nerve blocks

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 ?

• 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.

Abnormalities of stomach

• GDV

– Shock

– Benzodiazepines + opioids + Propofol, Etomidate, (Ketamin) + Iso, Sevo, Des

– Cardiac arrhythmias – Lidocaine

• Gastroduodenoscopy

– Opioids – ↑ tone of pyloric sphincter

– Acepromazine

• Small intestine

– Opioids (increased pyloric tone)

– Acepromazine, Midazolam

– Propofol, Etomidate, Alfaxalon

– Iso, Sevo, Des

• Large intestine

– ? Epidural anesthesia ?

– Rectum – recumbency – UPV

Intestinal abnormalities

Visceral analgesia

• Opioids + NSAIDA

– Buprenorphine + Metamizol, Carprofen, Meloxicam

• CRI

– Lidocaine

– Ketamin

– Dex/medetomidine

– Fentanyl, Morphine

Patient for

Cesarean section

4th study year FVM

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

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

• Short-acting anesthetics

• Anesthetics with antagonists

• L.A. – EPI

• Oxygen supplementation

• ETR

• Fluid therapy

• ABP monitoring

Anesthesia for CS

Anesthetics for CS I.

• Mu-opioids

– Respiratory depression, bradycardia

– Antagonisation

• Phenothiazines

– Prolonged metabolisation

– Vasodilatation

• Benzodiazepines

– Crossing placental barrier

– Depression of neurological functions

• 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.

• Alphaxalone

– CS in cats

– Fast clearance

• Local anesthetic

– Lidocaine

Anesthetics for CS III.

• 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

Patient with

ophthalmicdisease

4th study year FVM

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

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

• Lid and conjunctival surgery

– Without limitation

– According health status

• Eye globe surgery

– Without dissociatives

– Muscle relaxation + artificial lung ventilation

Anesthesia for ophthalmology II.

Patient with

endocrinedisease

4th study year FVM

Stress response

Disease

PyrogensEikosanoids

Tissue damageInfection

HypothermiaAcidosisHypoxia

Hypotension

Immobilization

HYPOTHALAMUS

CORTEX

Nociception

Receptor branch

Stress response

Hans Selye

Effector branch

Anesthetics

• Alfph-2 agonists

• Etomidate

• Thiopental

– Blockade of stress response in effector branch

– Corticoid supplementation

Adrenal gland pathology

• HYPERADRENOCORTICISM– Cushing

• HYPOADRENOCORTICISM– Addison

• FEOCHROMOCYTOMA

Increased level of glucocorticoids

• PU/PD, polyphagia

• Muscle weakness

• Abdominal cavity enlargement

• Hypoxemia

• Slow wound healing

• Hypercoagulation

• Lethargy

Hyperadrenocorticism

Anesthesia

• Respiratory insufficiency

– Weak abdomen, hepatomegaly

• Complicated venous access

• Hypertension and cardiomyopathy

• Risk of lung embolus

– Preoperative assessment of hemocoagulation

– Heparin, Hydroxyetylstarch

Preoxygenation

Premedication

– Diazepam, Midazolam, Acepromazin + Opioids

Induction

– Etomidate, Thiopental, Propofol, Alfaxalon

Maintenance

– Iso, Sevo, Des

– Propofol TIVA

Unilateral adrenalectomy

• Glucocorticoids supplementation

Bilateral adrenalectomy

• Glucocorticoids and mineralocorticoids supplementation

• Bradycardia

• Dehydration

• Weakness

• Lethargy

• PU/PD

• Weight loss

• …

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

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

Feochromocytoma

• Intermittent episodes

– Weakness

– Hypertension

– Tachycardia

– Heart arrhythmias

• Blood volume reduced

• PU/PD

• Collapse

Feochromocytoma

• Risk of catecholamine release – hypertension (in Ho)

– Tricyclic antidepressives (Amitriptyline)

– Droperidol

– Acepromazine

– Naloxone

– Metoclopramid

Feochromocytoma

Anesthesia

• High risk cardiologic patient

• Tachyarrhythmia

• Peroperative hypertension – postoperative hypotension

Pre- and postoperative stabilization

• Hypertension

• Tachycardia

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

• DIABETES MELLITUS

• INSULINOM

Abnormalities of homeostasis of glucose

Diabetes mellitus

• PU/PD

• Ketoacidosis

• Reduced liver function

• Weight loss

• (brain damage)

• …

Diabetic ketoacidosis

• Dehydration

• Hypovolemia

• Metabolic acidosis

• Hyponatremia

• Hypokalemia

• Marked hyperglycemia

• Vomiting

• Anorexia

• CNS depression

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

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

Diabetes mellitus

Premedication

– Diazepam, Midazolam + opioids

Induction

– Etomidate, Propofol, Ketamine, Alfaxalon i.v.

Maintenance

– Iso, Sevo, Des

– Propofol, Alfaxalon TIVA

Diabetes mellitus

Postoperative care

– Antagonisation

– Monitoring of glycaemia

– Small amount of food immediately, when able to eat

– Standard evening feeding

Insulinoma

Adenocarcinoma of beta-cells of Langerhans islets

• Intermittent hypoglycemia

• Ataxia

• Neurologic signs

• Stress intolerance

• Syncopes

• …

Insulinom

• Glucose monitoring (15–30 min)

• Postoperative hyperglycemia

– Insulin

• Anesthesia as in diabetic patients

– Glu ˃ 2,2 mmol l-1

– Risk of postoperative pancreatitis

Thyroid and parathyroid

• HYPERTHYREOSIS

• HYPOTHYREOSIS

• HYPERPARATHYREOSIS

• HYPOPARATHYREOSIS

Hyperthyreosis

• Hypertrophic cardiomyopathy

• Hypertension, tachycardia, arrhythmia

• Hyperthermia

• Restricted hepatic and renal functions

• Weight loss

• Aggressiveness

• PU/PD, polyphagia

Anesthesia

• ↑ metabolisation of anesthetics

• ↑ O2, glucose consumption

• ↑ CO2 production

Unsuitable

– Alpha-2 agonists

– Anticholinergics, Ketamine

Hyperthyreosis

Surgery

• Difficultness

• Pain

• Sedation

• Muscle relaxation

DEEP SEDATION

Patient

• Cardiovascular

abnormalities

• Metabolic

abnormalities

MINIMAL SEDATION

Hyperthyreosis

• Premedication

– Acepromazine

– Opioids

• Induction

– Induction chamber

– Propofol, Etomidate,

Alfaxalon

– ETR intubation

• Maintenance

– 5% glucose

– Iso, Sevo, Des

– Propofol, Alfaxalon TIVA

• Emergency cases

– Propofol, Alfaxalon

– Lidokain, Propanolol, Atenolol, Esmolol

– Hypocalcemia

Hyperthyreosis

Hypothyreosis

• Bradycardia

• Hypotension

• Megaesophagus

• Obesity

• Lethargy

• Hypothermia

• Reduced metabolisation

Hypothyreosis

Anesthesia

• Carefully negative inotropes

– Acepromazin, Isofluran

• Megaesophagus

– intubation

• Obesity

– Ventilatory support

Hypothyreosis

• Premedication

– Diazepam, Midazolam + Opioids

• Induction

– Etomidate, Thiopental, Propofol, Alfaxalon

• Maintenance

– Sevo, Iso, Des

– Propofol, Alfaxalon CRI

Hyperparathyreosis

• Monitoring of blood calcium

– Correction of hypercalcemia

– Monitoring of renal functions

• Risk of hypocalcemia after surgery

Hypoparathyreosis

• Most often after thyroid and parathyroid surgery

– Monitoring of blood level of Ca

• Calcium gluconate

• (Eclampsia ante-partum)

Increased production of estrogens

• Non-regenerative anemia

• Thrombocytopenia

• Febrile

• Immunosuppression

Sertolli cells tumor

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

anesthesiology of dog and cat · 2018-10-17 · anesthesiology of dog and cat a-a gradient healthy...

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