anesthesia monitoring bulger
TRANSCRIPT
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Anesthesia MonitoringSarah Ouellette CVT.
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Anesthesia and MonitoringGoals:
Provide a stage of reversible unconsciousness with adequate analgesia and muscle relaxation for surgical procedures that dose not jeopardize the animals health.
Identify problems early institute treatment promptly and avoid irreversible adverse outcomes
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Why we monitor?Anesthetic emergencies/complications:
Difficult to predictHappen quickly Become life threatening quickly
It is better to be proactive than reactive
Prevention is key!
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MonitoringRemember:
No monitoring device can take the place of constant human observation
The equipment we use only enhances our ability to monitor a patient
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Monitoring Starts when animal is dropped off
Pre-anesthetic evaluation includes History, Physical Exam
Ends after recovery period even day after
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Pre-anesthetic EvaluationHistory: what you want to know
Individual risk factors/underling problemsAge – certain risks for pediatric and geriatric
patientsBreed – brachiocephalic (long recovery) Temperament – aggressive/fractious (pre-med early)
Physical Exam – TPR, heart murmurs, lung sounds
Procedure – invasiveness, pain level
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Stages of AnesthesiaStage 1: Pre-medication
Stage 2: Induction
Stage 3: Maintenance Planes: 1 – 4
Stage 4: Recovery
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Stages1. Pre-medication:
IV or IM injection – sedation/pain relief Tranquilizer: no pain relief
ex: midazolam, acepromazine, diazepam
Add opioid for pain relief: ex: hydromorphone, fentanyl, buprenex, morphine
+/- anticholinergic: help maintain HR ex. atropine, glycopyrrolate
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StagesPre-medication:
Decreases need for increased induction agents and inhalant anesthetics
Aids for smoother induction and recovery
Place IV catheter during this stageMay start fluids or pain management CRI at
this time
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Stage 1: Pre-medicationWhat we monitor:
Heart rate
Respiratory rate
Perfusion – MM color/CRT
Pulses
Drooling/vomiting
Level of sedation
Reactions to medications
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Stages2. Induction:
Use Injectable anesthetics to yield an unconscious state
Ex: Ketamine, Propofol
Can be masked down with inhalant anesthetic Not recommended
Induction agents are given to facilitate intubation prior to being placed on an inhalant agent for maintenance
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Stage 2: InductionWhat we monitor:
HR/RR
Perfusion - MM color/CRT
Pulses
CNS reflex's – depth
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Stages3. Maintenance:
Unconscious + pain free
Inhalant anesthetic used to maintain unconsciousnessEx. Isoflurane, sevoflurane
Procedure is performed+/- IV fluids+/- Pain management CRI (fentanyl, MKL)
Procedure dependant
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Stage 3: MaintenanceWhat we monitor:
HR/RR
Perfusion - MM color/CRT
Pulses
CO2/O2 concentrations
Blood Pressure
CNS reflex's – depth
Temperature
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Stages 4. Recovery:
Good = uneventful
Inhalant turned off Extubated
Vitals monitored until awake/ambulatory every 5 – 10 min
Ideally warm quiet area
One of the most important stages of anesthesia morbidity is higher in this stage than any others
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Stage 4: RecoveryWhat we monitor:
HR/RR
Perfusion – MM color/CRT
Pulses
Temperature
CNS signs – consciousness
+/- Blood pressure
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Planes of AnesthesiaPlanes are used to describe depth of anesthesia
during the maintenance stage
Plane 1: light
Plane 2: medium
Plane 3: deep
Plane 4: too deep
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Planes of Anesthesia Plane 1 (light):
Regular HR
+/- irregular RR
Swallowing reflex decreases
Limb movements decrease
CNS signs present
Pain sensitive
Considerable jaw tone
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Planes of AnesthesiaPlane 2 (medium):
Suitable for procedures
HR + RR reactive to stimulus unconscious
3rd eyelid may rotate up
Skeletal muscle relaxes
Absence limb movements
CNS signs decrease
Jaw tone decreases
Normal blood pressure
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Planes of Anesthesia Plane 3 (Deep):
Decrease HR + RR even with stimulus
May need ventilation
Pulses weaken
Blood pressure drops
CRT prolonged
No jaw tone or CNS signs
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Planes of anesthesiaPlane 4 (too deep):
Significant decrease HR
Erratic jerky rest rate or apnea
No CNS signs
Pale gums – prolonged CRT
BP too low to read
Can be permanently damaging
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What is an ideal depth?Procedure dependent
Patient dependent
Good analgesia without depressing HR or RR
Low as possible vapor setting
IV analgesics safer (less detrimental effects) than increasing vapor setting but more difficult to adjust the depth
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MonitoringParameters we monitor during
anesthesia:
1. Central nervous system
2. Cardiovascular system
3. Respiratory system
4. Temperature
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Monitoring CNSVaries spp to spp and patient to patient
Good indication of DEPTH of anesthesia
CNS signs are called reflexes
Monitor multiple reflexes
Increase in anesthetic depth = a decrease of reflexes
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Common CNS reflexesEye position: Pupils begin in central position Then move
rostroventral in an adequate plane Then move BACK central as the patient moves into a deeper plane
More Effective in dogs
Ineffective if animal has received a dissociative drugEx. Ketamine - eyes are fixed centrally
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Eye Positioning
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Common CNS reflexesPalpebral reflex:
Touch medial or lateral canthus of the eye or eyelashes
Looking for a blink response
Weak/absent = adequate plane
May become desensitized if over tested
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CNS common reflexesPupil constriction/dilation:
• Induction – slt dilated or normal
• Maintenance: Plane 1+2 can constrict Planes 3+4 = more and more dilated
• Cats: unreliable if received atropine Dilated pupils
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Common CNS reflexesNystagmus:
Involuntary rapid movement of eyeball
Move side/side, up/down, rotary
Can happen in an excitement phase– common in animals that are masked down or given certain drugs
Important reflex in recovery period: Can be seen in dysphoric patients – common if given an
opioid Patients become light and sound sensitive
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Common CNS reflexesSwallowing:
• Spontaneous when awake
• Lost plane 1
• Regains after consciousness
• Important in recovery stage• Must be present before extubation to prevent
aspiration
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CNS common reflexesLaryngeal reflex:
Monitored during intubation
Arytenoids close to protect trachea
Elicited by tube stimulation
Induction decreases this reflex Lost plane 1Cats may need deeper plane to avoid
laryngospasms
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Larynx/Arytenoids
DO NOT TOUCH ARYTENOIDS Can cause laryngospasms
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Common CNS reflexes Cough reflex:
Monitored during intubation
Normal response in awake animals
Intact until plane 2
Common reflex in cats during recovery stage When extubation is warranted
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CNS common reflexesPedal reflex:
• Pinching digit or pad looking for withdrawal
• Lost by plane 2
• Movement = inadequate depth for surgery
• Shouldn’t be present with inhalant anesthesia
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CNS common reflexesEar/whisker reflex:
• Touch inner surface of pinna or whiskers • Looking for twitch response
• Present = inadequate depth for surgery
• Lost by plane 2
• May become desensitized → tested too often
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CNS common reflexesMuscle tone:
Present in light to medium planes
Jaw Tone: Opening jaw – estimate amount of resistance Want some resistance Flaccid jaw often indicative of excessive depth Less reliable in pediatric patients
Anal Tone: less reliable If present = too light for surgical stimulus
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CNS common reflexesResponse to surgical stimulus:
Movement
Lost by plane 2
Dramatic increase in HR and RR
Late indicator of inadequate depth
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Monitoring CirculationGoal:
Ensure adequate blood flow to tissues and vital organs
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How we monitor Circulation
Heart rate
Blood pressure
Tissue perfusion
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Monitoring HRHeart rate:
Base rate (resting rate) Breed, weight, age, fitness level play factor to base rate because of this it is difficult to define universal ranges for all patients
Normal:
• Dogs: 70 – 180 bpm
• Cats: 140 – 200 bpm
• Pediatric patients: dog 150-180bpm, cat 150-210bpm• They need a higher rate to maintain cardiac output
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Monitoring HRBradycardia: Low HR
< 60 dogs< 120 cats
Common causes:
Drugs/inhalants (have depressant effect) If patient is too deep
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Monitoring HRTachycardia: High HR
> 180 dogs> 220 cats
Common causes:PainDrugs
Ex. Atropine, gycopyrrolate, ketamine
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Monitoring HRHow we monitor heart rate:
1. Palpation
2. Auscultation
3. Pulse Oximeter
4. Electrocardiogram (ECG)
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Monitoring HRPalpation of chest for heart rate:
Difficult to feelLess reliable
Palpation of peripheral artery: Femoral, metacarpal, dorsal pedal, cranial tibial, lingual most common Count a rate Note the quality – normal, bounding, weak
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Common Palpable Arteries
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Monitoring HRAuscultation of the heart:
• Hand held stethoscope• Count rate• Detect murmurs
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Monitoring HREsophageal stethoscope:
Tube passed down esophagus connected to earpieces – creates an audible sound
Tip should be level with heart
Do not to pass into the stomach reflux/regurg
Note Rate and Rhythm
Can also hear respiratory rate and note character
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Esophageal Stethoscopes
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Monitoring HRPulse Oximeter:
Gives pulse rate
As well as SpO2 concentration
Machine detects pulsation from external probe and formats into a numerical value
Has become a standard of care in veterinary medicine
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Monitoring HRElectrocardiography (ECG):Shows electrical activity (cardiac cells)
Important for detecting arrhythmias
Also gives heart rate
DOES NOT give information about mechanical function of
heart (shouldn't be sole method for heart monitoring)
A deceased animal may still have electrical activity of the
heart but no actual beat
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Monitoring HRElectrocardiography (ECG)
Has 4 leads (most have 3): placed on armpit and flankWhite: Right frontBlack: Left frontRed: Left hindGreen: Right hind*
* this lead is commonly left out
Monitoring HR
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Monitoring HRECG Leads:
Need Good contact for proper function
Ultrasound gel VS. Alcohol as a conductor
Studies say ultrasound gel is better because:
Alcohol evaporates quickly and you need to reapply for longer procedures It also cools as is evaporates cause hypothermia
Monitoring HR
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ECG leads
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Monitoring HRElectrocardiograph: waveform
Provides regional information about the heartP waveQRS complexT wave
Each letter represents a location and function of heart
Abnormal waveform called arrhythmia
Monitoring HR
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Monitoring HRCommon causes of arrhythmias:
Heart dz #1
Pain
Drugs - (atropine and glycopyrrolate)
Electrolyte imbalances
Poor oxygenation
Monitoring HR
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ECG RhythmsNormal:
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Abnormal ECG RhythmsAtrioventricular Block (AV block)
Absence of QRS complex and T wave (dropped beat)
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Abnormal ECG RhythmsVentricular Premature Contractions (VPC’s)
Extra beat originating from from ventricles
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Monitoring Blood PressureBlood Pressure:
Force of the flow of blood on vessel walls measured in mmHg
Goal:
Maintain adequate blood flow and O2 delivery to tissues and vital organs
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Monitoring Blood Pressure Further defined:
Systolic pressure – SAP
Diastolic Pressure – DAP
Mean Pressure – MAP
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Monitoring Blood Pressure Normal ranges under anesthesia:
Systolic 80-150mmHg
Diastolic40-80mmHg
Mean - More important/accurate parameter Dogs: 60-100mmHgCats: 60-120mmhg
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Monitoring Blood Pressure Hypotension: low blood pressure
MAP < 60mmHgTissue perfusion is compromised
Common complication under anesthesiaDrugs/inhalants depressant
Tx/prevent: Lower inhalant, start fluids – give boluses, certain drugs
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Monitoring Blood Pressure Hypertension: high blood pressure
MAP > 175mmHg
Causes:
Underling Heart disease
Pain
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Monitoring Blood PressureDependent on:
Volume blood entering heart (before contraction)
Ability of heart to contract (muscle function)
Heart rate
Resistance to forward blood flow (vessel size)
Viscosity of blood
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Monitoring Blood Pressure How we monitor BP:
1. Oscillometric technique
2. Doppler technique
3. Arterial technique*
4. Central Venous Pressure technique*
* More common in critical patients not commonly used
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Monitoring Blood Pressure Oscillometric technique:
Indirect method – non-invasive
Cuff placed around major artery automatically inflated
Transducer within cuff detects pressure changes within artery
Records pulsations
Transmits # to screen
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Monitoring Blood Pressure Oscillometric technique:
Gives Mean, systolic, and diastolic parameters
SurgiVet monitor: labeled as NIBP
Data states systolic pressure is less accurate in this device
HOWEVER the mean value tends to be more accurate (mean is the more important value)
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Monitoring Blood Pressure Oscillometric technique:
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Monitoring Blood Pressure Doppler:
Indirect method
non-invasive
**ONLY used to
measure SAP**
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Monitoring Blood Pressure Pressure Cuff: both techniques
Need uniform compression of artery
Size cuff relative to limb being compressed
Width cuff should be 40% of the circumference limb
Cats can be 30-40%
Too small cuff = higher values
Too big cuff = low values
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Monitoring Blood Pressure Arterial monitoring: (gold standard)
Yields most accurate results
Direct method – Invasive method
IVC placed in dorsal pedal or metacarpal ARTERIESNeed a highly skilled technician Risks of infection and hemorrhage are high
Because of these reasons it is not common technique
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Monitoring Blood PressureArterial monitoring:
Catheter connected to electronic pressure transducer via extension tubing and transmits signal to monitor
Displays: SAP, DAP, MAP and constant waveform
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Arterial Catheter
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Arterial Catheter
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Monitoring Blood PressureCentral Venous Pressure
Reflects volume capacity of the right side of heart and amount of blood returning to the heart
Helpful in assessing fluid status (hydration)Need: jugular catheter
Normal range:0-5 cmH2O (trends more important than
individual numbers)
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Monitoring Tissue Perfusion
How we monitor tissue perfusion:
1. Palpation Artery
2. Mucus membrane color
3. Capillary refill time
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Monitoring Tissue perfusion
Palpation of peripheral artery: Femoral, metacarpal, dorsal pedal, cranial tibial, lingual commonly used Note the quality – normal, bounding, weak
Weak pulses = circulatory insufficiency
Monitored in conjunction with HR pulse should be synchronous with heart rate Every beat should have a pulse (pulse deficit)
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Monitoring Tissue perfusion
Mucus membrane color:
Should be pink and moist
Abnormal:Pale = vasoconstriction, blood loss or anemiaPurple or blue = cyanosisDry/sticky = dehydrated (dugs)Red/injected = heat stroke, sepsis, carbon
monoxide poisoning Yellow (icteric) = liver disease
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Mucus Membrane Colors
Normal
Pale
Icteric
Cyanotic
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Monitoring Tissue Perfusion
Capillary refill time:
Touch gums note time it takes for color to returnshould be < 2 sec
Prolonged = poor perfusion
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RespirationGoal:
Move O2 into the lungs and expel CO2 out
Ensure adequate O2 and CO2 concentrations in blood
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Physiology of Respiration O2 in arterial blood is carried to tissues
normal metabolism occurs CO2 byproduct or metabolism the CO2 is diverted into venous blood taken to heart travels to lungs capillaries in lungs CO2 transferred into alveolar sacs in lungs and expelled out O2 transferred from alveolar sacs into arterial capillaries travels back to the heart pumped into systemic circulation tissues
Then repeat!
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Anatomy of RespirationAlveolar sac:
Blue – venous blood from body high levels of CO2
Red – arterial blood high in O2 going back to the body
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Anatomy of Respiration
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Anatomy of Respiration Alveoli expand and contract with respirations
Deep breath into lungs expands more of sacs
Which increases surface area for exchange:
CO2 from capillary veins into alveolar sacs
O2 and anesthetic gas into arterial blood
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Monitoring Respiration Inhalants are #1 respiratory depressant!
Increase anesthetic depth = decrease in volume of air taken into the lungs (tidal volume) Decreases by 25%
Why?Drugs limit expansion of intercostal muscles
muscles we use to inspire
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Monitoring Respiration As tidal volume decreases the alveoli collapse
can decrease the function of lungs
Treat this by giving breath (bagging) – every 5 min
Watch the pressure monometer
Avoid over inflation of lungs
Never go over 20cmH2O
15cmH20 smaller patients
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Monitoring RespirationVaries between patients
Normal resting rates:Dogs 10 – 20 Cats 15 – 25
Under anesthesia:8-20 both spp.
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Monitoring RespirationCauses of decrease in respiration:
Drugs we give
Too deep
Heavy drapes or instruments on small patients
Dr. hand over patients chest
Low CO2 concentration
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Monitoring Respiration Causes of increase respiration:
Surgical stimulation
Too light/pain
Lung diseasePulmonary edema, pneumothorax, masses, ect.
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Monitoring RespirationHow we monitor respiration/ventilation:
1. Visual/listening
2. Monitoring CO2
3. Monitoring O2
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Monitoring RespirationVisual/listening:
Observe chest movements
Watch breathing bag
Handheld stethoscope
Listen to breathing sounds with esophageal
stethoscope gives rate and quality
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Monitoring CO2Respiratory Rate:
Can correlate to amount of CO2 in bloodNormal Value: 35-45 mmHG
To high (>50) can stimulate respiration (receptors in brain signal lungs to breath to eliminate the excess Co2)dependent on anesthetic depth, drugs, etc.
To low (<30) apnea or shallow breathing
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Monitoring CO2How we monitor CO2:
1. Blood Gas Analysis
2. Capnography
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Monitoring CO2Blood Gas: “GOLD STANDARD”
Most accurate determinant of CO2 levels in blood
Direct – invasive method
Need:Arterial blood sampleBlood gas analyzerSkilled technician Patient dependent – size, age
**Not common method**
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Monitoring CO2However…
Measuring end tidal CO2 (EtCO2) using capnography is useful alternative to estimate levels in blood (PaCO2) without invasive techniques
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Monitoring CO2Capnography:
Indirect – non-invasive method
Become most common method
Numerical +/- graphical display
Estimation of CO2 in arterial blood by the concentration of CO2 that is exhaled
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Monitoring OxygenationCapnoGRAPH tells us:
Graphical display CO2 that is exhaled
EtCO2 concentration
Resp rate
CapnoMETER tells us:
EtCO2 concentration
Resp rate
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Capnography
Capnometer
Capnograph
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Monitoring Oxygenation
Capnograph:
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Monitoring CO2Why is capnoGRAPH preferred?
Graphical display useful for determining:Airway obstruction Leak in endotracheal tube
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Normal CapnographGraphical display
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Abnormal Capnograph
Inadequately inflated endotracheal tube cuff
Damaged or leaking endotracheal tube cuff
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Abnormal Capnograph
Obstruction of endotracheal tubeBlood or mucus buildupKinked tube
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Monitoring CO2CO2 exchange is linked to:
1. Perfusion (blood flow) to capillaries in tissue and lungs
2. Ventilation (exchange alveoli sacs)
3. Metabolism (production of CO2)
** Keep in mind all of these factors when looking at
the values on the monitors**
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Monitoring O2SpO2:
Measures level of arterial O2 in saturated hemoglobin hemoglobin in RBC is the O2 carrying component in blood
Gives us an estimation of oxygenation
Helps us to determine need for O2 supplementation
SpO2 should be > than 95%98-100% under anesthesia
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Monitoring O2O2 exchange is linked to:
1. Perfusion (blood flow) in tissues and lungs Any factor that inhibits blood flow can
affect these results
2. Ventilation (exchange alveoli sacs)
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Monitoring O2How we monitor O2:
1. Blood Gas Analysis
2. Pulse Oximeter
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Monitoring O2Blood Gas: “GOLD STANDARD”
Most accurate determinant of O2 levels in blood
Direct – invasive method
Need:Arterial blood sampleNeed blood gas analyzerSkilled technician Patient dependant – size, age
*Not commonly used*
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Monitoring SpO2Pulse Oximitry:
Non-invasive – indirect method
Two red light wavelengths pass through body tissue
O2 rich blood blocks less red light than oxygen depleted blood
Separates parameters and gives a numerical % of O2 saturation
Also gives us a Heart rate
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Pulse Oximeter machines
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Pulse OximetrySurgi-Vet Monitor
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Monitoring SpO2Probes:
Tongue – most common in anesthetized patients
Can be placed on lip, ear, inguinal skin fold, toe web, tail, skin along achilles tendon, prepuce or vulva
If placed on ear/lip red light should be inside facing out
Light should face down to avoid risk of ambient light can lead to falsely increased
values
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Pulse OximetryProbes
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Pulse Ox equipmentRectal probe:
Rectum must be free of excess foreign material
Light positioned dorsally
Anchor it to the tail with tape
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Monitoring SpO2Causes of low readings:
Pigmented skin
Tissue thickness
Anemic animals
Poor perfusion Check mm color and CRT for abnormal readings
Tylenol toxicities (destroys hemoglobin)
Reposition probe (every 5 - 10 min) Probe itself can occlude vessels and decrease results
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Monitoring SpO2High readings:
Falsely increased
Florescent lightsPlace drape or towel over probe
Important to check other parameters too!MM/CRT
**if an animal has pale gums but a high SpO2 you may need to troubleshoot**
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TemperatureGoal:
Maintain a body temperature adequate for normal metabolic functions
Avoid accidental hypothermia or malignant hyperthermia
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TemperatureNormal:
99.5 – 102.5F
Hypothermia: low temp
Hyperthermia: high temp
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Monitoring temperatureHypothermia:
Common complication under anesthesia
Loose heat rapidlyFirst 20 minutes most loss
Stay above 98 degrees for not to be detrimental to patient
Dramatically slows anesthetic recovery
Monitor every 15 – 30 min, as well as post-op until normal
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Monitoring TemperatureWhy they get so cold?
Shave fur
Scrub with fluids that cool as they evaporate
Take away their inability to shiver
Open body cavity to room air
Drugs/inhalants
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Monitoring TemperatureTreating hypothermia:Prevention. Prevention. PreventionWarm IVF Hot water pads/blanketsBubble wrap feetWarm blankets Bair huggers
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Monitoring TemperatureTreating hypothermia:
Hot water bottles/fluid bags in towels
** NEVER direct contact with patient**
heat + pressure + time = necrosis
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Monitoring TemperatureCauses of hyperthermia:
Excessive application of heat in attempt to prevent hypothermia
Infections
Cats – adverse reaction to hydromorphone
Ketamine
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Monitoring temperatureTreating hyperthermia
Remove blankets from cage
Place ice packs in towels in cageNot directly on the patient
** REMEMBER: if methods are being used to treat hyperthermia, the temperature should be monitored
closely to prevent subsequent hypothermia **
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How We Monitor Temperature
Manually – hand thermometer
Esophageal probe
Rectal probe
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Thermometer probes
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Record Keeping
How we keep it all together
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Record keeping Goal:
Maintain a legal record of significant events during the anesthetic period
Recognize trends or unusual values or parameters and allow assessment of response to intervention
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Record KeepingUseful for 4 main reasons:
1. See trends in patient vitals address problems
2. Archive record to compare similar cases (statistical analysis)
3. Reference for anesthesia in future
4. Legal document so it needs to be complete and easy to read
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Record KeepingAnesthesia record/sheet should have:
Patient ID
Procedure
Pre-op findings
Drugs given – dose, time, route
Pre-op TPR
Vitals – 5 min during procedure
Unusual circumstances – arrhythmias, drug reactions, regurgitation ect.
O2 and inhalant anesthetic rates
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Record KeepingTypes of anesthesia sheets
1. Graphical
2. Numerical
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Graphical
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Numerical
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In ConclusionNo SINGLE criteria tells you how an animal is
handling anesthesia
Add up vitals and reflexes to determine a safe anesthetic depth
Make sure anesthetic procedure is properly documented
NEVER be afraid to ask a Dr. or another technician
The only dumb question is the one not asked!