Anesthesia And Analgesia Book 3 - Banfield Pet Hospital
ProtocolsCPR Clinical GuidelinesANESTHESIA andANALGESIAAppendixfor the Veterinary Practitioner:Canine and FelineBook 3
ASA STATUSStatusASA ClassifcationExamplesIHealthy pet, no diseaseElective OVH or castrationIIMild systemic disease orlocalized diseaseHealthy geriatric pet, mildanemia or obesityIII (fair)Moderate systemic disease Mitral valve insufciency,limiting activity but notcollapsing trachea, poorlylife-threateningcontrolled diabetesIV (poor)Severe systemic disease;incapacitating; lifethreatening; not expectedto live without surgeryHemoabdomen fromsplenic rupture, severetraumatic pneumothorax,organ failureV (grave)Moribund; not expected tolive 24 hours, with orwithout surgeryMulti-organ failure, severeshock, terminal malignancyDetermine the pet ASA status HistoryClinical Pathology DataPhysical ExamI -II There is little to no increase in riskIII - V Discuss increased risk with the client Maximize preanesthetic medicalmanagement Cancel or refer procedure asclinically indicatedCLINICALESSENTIALThe attendingveterinarianchooses protocolsand determinesspecifc drugdosages
ANESTHESIAandANALGESIAfor the Veterinary Practitioner:Canine and FelineBook 3 2017 Banfeld Pet HospitalISBN # 978-0-9743262-8-3All rights reserved. Reproduction in whole or in part without the express written permissionof Banfeld Pet Hospital, is prohibited.
PREFACE Individual state practice act requirements and DEA regulations must bemet or exceeded in all instances. Review Medical Quality Standards. Meet or exceed all Clinical Essentials.STATE REGULATIONS: At all times, every medical team must comply with individual statepractice acts. It is each doctor’s responsibility to know and understand therequirements of his/her specifc state, as well as Banfeld policiesand procedures. The doctor must ensure compliance with state regulations regarding: Handling and administration of controlled substances Intubation of pets Anesthetic monitoring Drug administration documentation Which hospital associates can legally perform dental prophylaxis andall other medical procedures Of-label usage of medicationsThis publication may contain information that is not within the currentFDA-approved labeling for several products for companion animals.
MAJOR CONTRIBUTING AUTHORSNora S. Matthews, DVM, DACVAAProfessor Emeritus, Texas A & M UniversityDr. Matthews graduated from Cornell University College of Veterinary Medicine and was inpractice (in upstate New York) before returning to Cornell for an anesthesia residency. Shewas on faculty at Washington State and Oklahoma State University before going to Texas A& M University in 1989. She spent 24½ years there before retiring in July 2013. She hasalways been a clinical anesthesiologist, spending 50 percent (or more) time on clinics in theteaching hospital.Dr. Matthews has published more than 60 articles in refereed journals and numerousbook chapters on anesthesia and analgesia with a subspecialty in pharmacokineticsand anesthesia of donkeys and mules. She also has a particular interest in monitoringequipment. As the past president of the American College of Veterinary Anesthesia andAnalgesia she has also spoken at over 150 veterinary meetings, from local to international.While she has enormously enjoyed her time at universities, she is enjoying being a reliefanesthesiologist in various clinics and working with residents in practice.David D. Martin DVM, DACVAASenior Veterinary SpecialistZoetisDr. Martin received his DVM in 1987 from the University of Missouri-Columbia. He thencompleted a small animal medicine and surgery internship at Texas A & M Universityin 1988. Afer three years in private emergency practice, Dr. Martin then completed aresidency in veterinary anesthesiology at the University of Illinois-Champaign/Urbana in1995 and became board certifed in 1997. He held faculty positions at the University ofMissouri-Columbia from 1995-1997 as a clinical instructor and at Purdue University from1997-2001 as an assistant professor. In 2001, he joined Pfzer (now Zoetis) where he iscurrently a senior veterinary specialist. Dr. Martin is also a past president of the AmericanCollege of Veterinary Anesthesia and Analgesia.Jo Ann Morrison, DVM, MS, DACVIMSenior Manager, Medical ProgramsBanfeld Pet HospitalDr. Morrison received her DVM degree from Purdue University in 1993. Afer fve yearsof general and mixed animal practice, she completed a small animal internal medicineinternship at Afliated Veterinary Specialists in Maitland, Florida. From 1999-2002 shecompleted a residency at Iowa State University, achieving board certifcation in small animalinternal medicine in 2002. Afer two years of private referral specialty practice in Florida,she returned to Iowa State and was a faculty clinician for 11 years. She completed hermaster’s degree in veterinary clinical sciences in 2004 and served as the residency programdirector and the section head of small animal internal medicine. In 2015 she joinedBanfeld as a senior manager on the Medical Quality Advancement team.
hepatic4Brachycephalic12Caesarean section20Cardiac28Dental prophylaxis38Diabetic (stable)46Emergency54Geriatric62Hands-free radiology72Obese (stable)78Onychectomy (medically al110Respiratory compromise120Sof tissue (elective)130Stressed/fractious138Addendum147
CPR CLINICAL GUIDELINESPreparedness and Prevention150Equipment150Resuscitation aids150Training150Basic Life Support152Defnition152Recognition152Chest compressions153Ventilation154Advanced Life Support155Monitoring157Post-cardiac Arrest Care159APPENDIXMedication Dilution and Combination167Advanced Analgesic Techniques169Constant rate infusions170Wound infusion catheters178Dosage Charts183
ABDOMINAL/HEPATICPROTOCOLSNora S. Matthews, DVM, DACVAADavid D. Martin, DVM, DACVAAJo Ann Morrison, DVM, MS, DACVIMABBREVIATIONSABCB1 updated name forMDR geneACVIM American College ofVeterinary InternalMedicineALPalkaline phosphataseALTalanine aminotransferaseASAAmerican Society ofAnesthesiologistsbpm beats per minute orbreaths per minute,depending on contextBUN blood urea nitrogenCNScentral nervous systemCRIconstant rate infusion1Book 3DKTdexmedetomidine,ketamine, torbutrolECGelectrocardiogramEtCO2 end-tidal carbon dioxideGIgastrointestinalGDV gastric dilatation volvulusMAP mean arterial pressureMDR multi-drug resistantNRBnon-rebreathingNSAID nonsteroidalanti-inflammatoryOVH ovariohysterectomySpO2 peripheral capillary oxygensaturationTPRtemperature, pulse,respiration
PROTOCOLSINTRODUCTIONThe clinical essentials and best practices for anesthetic procedures, alongwith references, are provided inside the front and back covers of book 1.Hospital teams should read carefully and familiarize themselves with theseMedical Quality Standards.Protocols have been developed from an evaluation of the current literatureand the consensus of board-certifed veterinary specialists (anesthesiologyand internal medicine). Protocols are never meant to be followed blindlyand the anesthesia team remains responsible for making decisions in thebest interest of the patient.Examples: If a protocol calls for cefazolin but the patient is allergic tocephalosporins, administer a diferent antibiotic If a protocol utilizes acepromazine, but the patient is undergoingmedical therapy for a portosystemic shunt, administer a diferentpremedicationProtocols2
PROTOCOLSWhy do we need diferent protocols for diferent patients if thegoals of anesthesia (analgesia, unconsciousness and musclerelaxation) are the same for all?Healthy patients have the highest requirements (in mg/kg) for drugsespecially if they are very nervous or very active. These patients usuallyhave increased physiologic reserve in organ and cardiac function.Remember that an unremarkable physical examination does not precludethe presence of underlying pathology. The Medial Quality Standardschapter includes examples of potential genetic or breed-associatedconditions, which may impact anesthetic decision making.Generally, consider the need to reduce drugs or drug dosages for older,sicker patients or substitute a drug with fewer side efects depending ondisease and American Society of Anesthesiologists (ASA) status.Considerations for all patients Premedication should be appropriate for the patient (see specifcprotocols) and given 30 minutes before induction (route dependenton medication). Wait 30 minutes to allow premedications to take full efect beforeinduction, unless patient status dictates otherwise. Premedications are generally administered to provide anxiolysis(e.g., tranquilizers and sedatives) and preemptive analgesia. Repeat physical exam and temperature, pulse, respiration (TPR) priorto induction. If any part of TPR has changed signifcantly and raisesconcern, stop and reevaluate the patient. Complete Anesthetic Machine Checklist prior to each anestheticprocedure. Plan analgesic protocol and implement as appropriate for each patient. Use of reversal agents should be made on an individual patient basis.See Induction, Monitoring and Recovery chapter for details.3Book 3
ABDOMINAL/HEPATICABDOMINAL/HEPATICWhat is diferent about this patient?There are multiple clinical scenarios where abdominal surgery may beperformed with a variety of comorbidities: Abdominal mass removal Cystic calculi Gastric dilatation volvulus (GDV) Gastrointestinal (GI) foreign body Hepatic biopsy PyometraDepending on the underlying etiology, patients may require a largenumber of stabilizing procedures before becoming anesthetic candidates(e.g., GDV), or may be hemodynamically stable with a relativelyunremarkable physical examination (e.g., cystic calculi removal).A range of analgesic requirements may exist and analgesic plans shouldbe individualized to each patient. Certain conditions may be associatedwith nausea or vomiting, so the addition of antiemetics (e.g., maropitant)should be considered when medically indicated.Elevated hepatic enzymes (ALT and ALP) may be seen in many of thesepatients, so close attention should be paid to potential indicators ofhepatic dysfunction and supportive measures be proactively prepared.EXAMPLESHepatic DysfunctionInterventionHypoglycemiaDextrose CRIHypoalbuminemiaColloid supportCoagulopathyVitamin K or transfusion therapyProtocols4
eCanine 0.05 - 0.2 mg/kgFelineMidazolamRouteIM, SC0.05 - 0.1 mg/kg0.1 - 0.3 mg/kgIM, SCORif there is a history of vomiting:Midazolam0.1 - 0.3 mg/kgIM, SCButorphanol0.2 - 0.4 mg/kgIM, SC Provide antiemetic support (maropitant) if vomiting Consider if additional analgesic therapy is warranted based on: Signalment Anesthetic indication Physical examination Surgical intervention planned If additional analgesic therapy is warranted, replace butorphanol inthe premedication with another opioid listed in Additional AnalgesicTherapyADDITIONAL ANALGESIC THERAPYDrug5DoseRouteHydromorphone0.05 - 0.1 mg/kgIM, SCBuprenorphine0.01 - 0.02 mg/kgIM, IVBuprenorphine –long actingFeline 0.24 mg/kgSC onlyBook 3
ABDOMINAL/HEPATICINDUCTION AND INTUBATIONDrugPropofolDoseRoute1.0 mg/kg slowly over 15 secondsIVIncrements of 0.5 mg/kg over15 seconds until intubation Preoxygenate if possible, based on patient tolerance and clinicalstability Induce with lowest possible dose of propofol May cause apnea if given rapidly Bradycardia, hypotension and respiratory depression maydevelop afer rapid administrationTRANSITION PHASEPost-induction Inhalant RatesInhalantOxygenRates50 - 100 mL/kg/minute(rebreathing)MiscellaneousFor frst 15 minutesafer induction150 - 300 mL/kg/minute(non-rebreathing (NRB))Sevoflurane3% for 3 minutesLarge dogs mayneed higher rates Monitor anesthetic depth and oxygenation closelyProtocols6
ABDOMINAL/HEPATICANESTHETIC MAINTENANCEDrugsOxygenRates20 - 30 mL/kg/minute (rebreathing)200 mL/kg/minute (average rate, NRB)Sevoflurane1 - 4% to efect with oxygen Prevent/treat hypothermia associated with a large, open abdomen(see Induction, Monitoring and Recovery chapter for details) Be prepared to adjust oxygen flow rates in response to patientclinical parameters Amount of sevoflurane will vary with patient health, analgesic therapyand local blocks used If 4% or more sevoflurane is required: Check the anesthesia system for leaks Ensure appropriate analgesia Consider: Inadequate premedication Improper endotracheal intubation, etc. See Equipment chapter for more detailsNotes7Book 3
ABDOMINAL/HEPATICPERIOPERATIVE ANESTHETIC SUPPORTIntravenous FluidsCrystalloidsRateCanine 5 mL/kg/hourFelineColloids3 mL/kg/hourCanine 20 mL/kg/dayORBolus of 5 mL/kgFelineMiscellaneousConsider avoidinglactate in patientswith hepaticdiseaseIf medicallyindicated20 mL/kg/dayORBolus of 2.5 mL/kgAnticholinergicsDrugDoseRouteAtropine0.02 - 0.04 mg/kgIVGlycopyrrolate0.005 - 0.01 mg/kgIV Depending on preanesthetic blood glucose (BG) readings, BG mayneed to be checked intraoperatively and postoperatively IV dextrose infusion at 2.5 - 5% may be utilized to support BG in thehypoglycemic patient Intraoperative analgesia as indicated by patient clinical status See The Individualized Anesthesia and Analgesia Plan chapterfor details Anticholinergics as clinically indicated for bradycardia accompaniedby hypotensionProtocols8
ABDOMINAL/HEPATICLOCAL BLOCKS AND ANTIBIOTICSLocal BlockLine block for abdominal incisionLidocaine (2 mg/kg) ORbupivacaine (1.5 mg/kg)AntibioticsAs medically indicatedSee Medical Quality Standardschapter Dilute local anesthetic as needed to obtain adequate volumefor administration Pay attention to maximum cumulative doses Perform blocks once patient is under general anesthesia and the frstof 3 sterile skin preps has been performedANESTHETIC RECOVERYParameterRangeNormothermicTemp 100 - 102.5 FNormotensiveMAP 80 - 100 mm HgOxygenating normally on room airSpO2 95 - 100%Sternal recumbencyPain controlledPain score 2 If recovery is slow, recheck BG concentrations9Book 3
ABDOMINAL/HEPATICPOSTOPERATIVE CARE AND PAIN MANAGEMENTDrugDoseRouteOPIOIDButorphanol0.2 - 0.4 mg/kgIMBuprenorphineCanine0.005 - 0.02 mg/kgIMFeline0.01 - 0.02 mg/kgIM, TransmucosalFeline0.24 mg/kg(dose on lean bodyweight)SC only0.01 - 0.2 mg/kgSC, IM0.005 mg/kgIV every 2 - 4 hours0.05 - 0.1 mg/kgSC, IM0.05 mg/kgIV every 2 - 6 hoursBuprenorphine– long actingHydromorphoneCanineFelineFentanylSee Appendix chapter for details IV as CRI Opioids are most commonly used Avoid NSAIDs when possible Adequate pain management must follow through postoperative periodand facilitates anesthetic recovery Consider premedication utilized when choosing postoperativeanalgesics Pain scores of 2 and greater should be treated with analgesicmedications Watch for potential hyperthermia in cats with opioid therapy Do not confuse pain with dysphoria, refer to Induction, Monitoring andRecovery chapter for detailsProtocols10
ABDOMINAL/HEPATICANALGESIA TO GO HOMEDrugTramadolDosageCanine 5 mg/kgFelineRoutePO, every 6 hours2 - 4 mg/kgORBuprenorphineFeline0.01 - 0.02 mg/kgTransmucosal,every 8 hours Use opioid as appropriate for health status Avoid NSAIDs when possibleNotes11Book 3
BRACHYCEPHALICBRACHYCEPHALICWhat is diferent about this patient?Most brachycephalic patients, either canine or feline, have difcultybreathing when awake. Small nares, elongated sof palates andhypoplastic tracheas create a very abnormal upper airway.Some breeds (e.g., Pugs and Bulldogs) are more likely to be obese, whichfurther exacerbates breathing problems Stress increases respiratory rate and can cause serious complicationssuch as hyperthermia or respiratory collapseBrachycephalic patients (Bulldogs in particular) may not be goodcandidates for procedures using sedation; general anesthesia may be saferfor them. See Sedation and Immobilization chapter for more information.All sedatives and anesthetic drugs impair respiratory function bycentral (neurologic) depression and relaxation of muscles needed formaintaining an airway. Patients must be carefully monitored frompremedication through recovery.EXAMPLESANY pet with a shortened snoutBoston TerrierBoxersBulldogsHimalayanLhasa ApsoPersianPugsShih TzuORANY pet with a functional or anatomic abnormality of the larynx,pharynx, esophagus or tracheaLabrador Retriever withlaryngeal paralysisShar PeiProtocols12
l0.2 - 0.4 mg/kgIMMidazolam0.1 - 0.3 mg/kgIMORHydromorphone0.1 mg/kgIMMidazolam0.1 - 0.3 mg/kgIM Never muzzle or restrict the airway in any brachycephalic patient anduse minimum physical restraint necessary Anxiolytics may be helpful but should not be used in place of safepatient handling practices Cautious use of acepromazine at low-dose (0.01 mg/kg) may beconsidered if patients are signifcantly anxious Butorphanol may be preferred as a premedication since it producesless panting (and may be less likely to produce vomiting) thanhydromorphone Patient analgesic needs should be considered Maropitant may also be considered for brachycephalics to reduce therisk of vomiting Pre-oxygenation is very important for these patients if they willtolerate it, but stress should be kept at a minimum13Book 3
BRACHYCEPHALICINDUCTION AND INTUBATIONDrugPropofolDoseRoute1.0 mg/kg slowly over 15 secondsIVIncrements of 0.5 mg/kg over15 seconds until intubation Preoxygenate if possible, based on patient tolerance andclinical stability Induce with lowest possible dose of propofol May cause apnea if given rapidly Bradycardia, hypotension and respiratory depression maydevelop afer rapid administration It is important to have a range of endotracheal tube sizes availablein the case of a hypoplastic trachea The average Bulldog may take a 6.5 mm tube (approximate size),instead of the 9 mm tube one might anticipate based on body sizeTRANSITION PHASEPost-induction Inhalant RatesInhalantOxygenRates50 - 100 mL/kg/minute(rebreathing)MiscellaneousFor frst 15 minutesafer induction150 - 300 mL/kg/minute(NRB)Sevoflurane3% for 3 minutesLarge dogs mayneed higher rates Monitor anesthetic depth and oxygenation closelyProtocols14
BRACHYCEPHALICANESTHETIC MAINTENANCEDrugsOxygenRates20 - 30 mL/kg/minute (rebreathing)200 mL/kg/minute (average rate, NRB)Sevoflurane1 - 4% to efect with oxygen Once intubated these patients usually do well due to upper airwaybypass (until extubation) Be prepared to adjust oxygen flow rates in response to patientclinical parameters Amount of sevoflurane will vary with patient health, analgesic therapyand local blocks used If 4% or more sevoflurane is required: Check the anesthesia system for leaks Ensure appropriate analgesia Consider: Inadequate premedication Improper endotracheal intubation, etc. See Equipment chapter for more detailsNotes15Book 3
BRACHYCEPHALICPERIOPERATIVE ANESTHETIC SUPPORTIntravenous FluidsCrystalloidsRateMiscellaneousCanine 5 mL/kg/hourHigher fluid rates maybe needed if patientis not adequatelyhydrated whenanesthesia beginsFeline3 2 - 0.04 mg/kgIVGlycopyrrolate0.005 - 0.01 mg/kgIV Brachycephalic patients may have high vagal tone withprofound respiratory sinus arrhythmias and may beneft fromanticholinergic therapy Intraoperative analgesia as indicated by patient clinical status See The Individualized Anesthesia and Analgesia Plan chapterfor detailsLOCAL BLOCKS AND ANTIBIOTICSLocal BlockAs medically indicatedPay attention to maximumcumulative dosesAntibioticsAs medically indicatedSee Medical Quality Standardschapter Dilute local anesthetic as needed to obtain adequate volumefor administration Perform blocks once patient is under general anesthesia and the frstof 3 sterile skin preps has been performedProtocols16
BRACHYCEPHALICANESTHETIC RECOVERYParameterRangeNormothermicTemp 100 - 102.5 FNormotensiveMAP 80 - 100 mm
always been a clinical anesthesiologist, spending 50 percent (or more) time on clinics in the teaching hospital. Dr. Matthews has published more than 60 articles in refereed journals and numerous book chapters on anesthesia and analgesia with a subspecialty in pharmacokinetics and anesthesia of donkeys and mules.
General (Reptiles and/or Amphibians): This section contains literature discussing anesthesia and analgesia for the two classes, reptiles and amphibians (all species), or covering more than one species. Alligators, Crocodiles, and Caimans: This section covers anesthesia/analgesia for reptiles of the order Loricata. Bearded dragons:
from the ASA Committee on Practice Parameters. This Practice Guideline is an update and revision of the ASA “Guidelines for Sedation and Analgesia by Non-Table 1. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia Minimal Sedation (Anxiolysis) Moderate Sedation/Analgesia
Feb 12, 2021 · analgesia/anesthesia care Hysterectomy informed consent and acknowledgement statement 01966 Anesthesia for induced abortion procedures Physician/practitioner notes or operative report 01969 Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition
to anesthesia, pain, and analgesia in the Hippocratic Collection and to relate some of them to modern Greek terms. It is the study of texts in their original language that helps us to improve our understanding of medicine and anesthesia in the 21st century. METHODS The wor
2.1 These guidelines are concerned with the management of epidural analgesia in the hospital setting in the United Kingdom, including continuous infusions, patient-controlled epidural analgesia (PCEA) and intermittent top-up injections. 2.2 These guidelines are not concerned with the management of epidural analgesia for persistent
The shortage of qualified anesthesia providers and the increased demand for anesthesia services create a highly competitive marketplace. Weigh the compensation of the current anesthesia team against the local market rate. ANESTHESIA SUBSIDY Hospitals provide additional financial support in the form of anesthesia subsidies to
Jul 20, 2017 · Delivery: An Analysis of the National Anesthesia Clinical Outcomes Registry." Anesthesia & Analgesia 124, no. 6 (2017): 1914-1917. Specific Aims 1. Build two parallel databases (local and national) to elucidate variability relating to obstetric anesthesia care. 1. Using multivariable regression and the databases
Trustee Joy Harris Jane Gardener Simon Hebditch Trustee Sarah Howell- Davies Jill Batty Cartriona Sutherland treasurer Verity Mosenthal Jenny Thoma Steve Mattingly Trustee Anne Sharpley Lynn Whyte Katy Shaw Trustee Sandra Tait Tina Thorpe Judith Lempriere The position of chair is contested so there will be an election for this post Supporting Statements David Beamish Standing for Chair I .
