Clinical Standards in Veterinary Anesthesia

Can we improve veterinary anesthesia?

Safe anesthetics and analgesics are available Needed anesthetic and monitoring equipment are available Needed expertise and instructions are available

What Really Works in Anesthesia / Pain Management?

What really works well practical, reasonable, & profitable What I can implement for my practice What brings success for my hospital patients, clients, staff

AAHA Anesthesia Guidelines for Dogs and Cats

Goal of the Guidelines: Improving patient care across all veterinary practices

Ralph Harvey, DVM, MS, Diplomate ACVA University of Tennessee CVM

Anesthesia is a real concern for all informed parties.

Veterinarians and their staff desire to make anesthesia successful in all regards, not just immediate survival and recovery. Our clients do worry about anesthesia. They want to know that Everything is OK. Their anxiety is real and it is fully justified!

Problem-Based Anesthesia
Problem-based anesthetic management serves as the framework for our individualized patient care.
Choices of anesthetic medications, monitoring, and supportive care are all based on recognition of the individual patients needs. Get everything ready before inducing anesthesia.

Anesthetic Concerns
Appropriate patient evaluation provides for the recognition of anesthetic risks and/or anesthetic concerns for that specific patient and procedure.

Focused monitoring and patient evaluation lead to

individualized patient care. Keep it safe for personnel Control waste gases

Implementing the anesthesia standard from start to finish

PRIOR to Anesthesia
Patient evaluation Individualized plan development Owner instructions for night before/day of anesthetic event Informed consent Equipment inspection

How Risky? - ASA Physical Status 1-5

Modified from: American Society of Anesthesiologists

ASA Physical Status Category - With examples of each category:

ASA 1 Normal healthy patients
No discernable significant disease; elective ovariohysterectomy or castration

ASA 2 Patients with mild systemic disease

Skin tumor, simple fracture, uncomplicated hernia, cryptorchidectomy, localized infection, compensated disease

ASA 3 Patients with severe systemic disease

Fever, dehydration, anemia, cachexia, or moderate hypovolemia; co-morbidity influencing anesthesia

ASA 4 Patients with severe systemic disease that is a constant threat to life
Uremia, toxemia, severe dehydration and hypovolemia, anemia, cardiac decompensation, emaciation, or high fever

ASA 5 Moribund patients not expected to survive with or without operation

Extreme shock and dehydration, terminal malignancy or infection, or severe trauma

Equipment Checklists Pilots use them, so should we!

Anesthetic Equipment & Supplies

A. B. C. D. Electrocardiogram Pulse Oximeters Blood pressure Blood gases

Anesthetic Equipment & Supplies

Anesthetic agents & appropriate antagonist agents

Anesthetic Equipment & Supplies

Anesthetic agents & appropriate antagonist agents

Anesthetic Equipment & Supplies

Anesthetic agents & appropriate antagonist agents

Anesthetic Equipment & Supplies

Anesthetic agents & appropriate antagonist agents

Anesthetic Equipment & Supplies

Anesthetic agents & appropriate antagonist agents

Anesthetic Equipment & Supplies

Injectable Anesthetics Inhalant Anesthetics

Inhalant Anesthetics

General
Equipment troubleshooting, awareness of health hazards and a means of assisting ventilation

Designated recovery area

Patient Monitoring
A practice team member is dedicated solely to monitoring the condition of each anesthetized patient

Patient Monitoring
The following equipment is utilized during anesthetic procedures: a) Pulse oximeter / Doppler b) Blood pressure monitor c) Continuous electrocardiograph (ECG) monitor d) Respiratory monitor or capnograph

Anesthesia Monitoring
Vigilant monitoring, properly-functioning equipment, and well-trained and attentive staff are essential for interpreting monitoring data, identifying and responding to changes in patient physiologic status.

Why monitor?
Is the patient adequately anesthetized and immobilized? Is the patients pain adequately managed? Is the autonomic response adequately subdued?

Why monitor?
What are the current physiologic consequences of anesthesia? Are observed abnormalities serious enough to warrant treatment?

Recommendations for Monitoring Anesthetized Veterinary Patients:

ACVAA Monitoring Guidelines Update, 2009 Document
These guidelines were approved by the Diplomates of the ACVAA in December of 1994, and first published in the Journal of American Veterinary Medical Association on April 1, 1995. (JAVMA, Vol. 206, No. 7, 936-937.

OSHA Safety and Health Topics: Waste Anesthetic Gases

Some potential effects Employers and employees should be aware of the potential effects of waste anesthetic gases and be advised to take appropriate precautions.
In the United States, OSHA requires individual veterinary hospitals and practices to maintain a system to prevent waste gases from building up in the area of use
http://www.osha.gov/SLTC/wasteanestheticgases/index.html
ACVA Commentary and recommendations on waste anesthetic gases in the workplace http://www.acva.org/professional/Position/waste.htm

Risk factors and occupational hazards:

the level of WAG depends on the presence of gas scavenging systems, good anesthetic practices, and periodic examination and maintenance of anesthetic machines Johnson: http://www.cfpc.ca/cfp/2000/Dec/03_01.html

Effective waste anesthetic gas management includes: Engineering Controls, Work Practices, Air Monitoring Hazard Communication and Training

Waste Anesthetic Gas Evacuation Systems:

Pop-off Valve 19mm tubing

Scavenger interface

Scavenger Systems
Must be accompanied by good technique to reduce exposures! Scavenging removes waste gases from popoff valve only, not leaks or technical errors Removes waste anesthetic gases from work area Interface and relief valves
positive and negative relief

Reservoir (often a reservoir bag)

Activated charcoal canisters:

This canister will last approximately 12-15 hours of average surgery time. However, the true test is to weigh the unit. The canister can retain 50 grams more than when you started using it. No warning when full!

Getting started with the first case of the day

Preanesthetic Evaluation
Patient history Physical exam Diagnostic test(s)

Anesthesia Plan Development

Knowledge of specific and underlying disease Functional status of cardiopulmonary system Response to preoperative stabilizing measures Knowledge of drugs and effects

Anesthesia Plan Development

Address all phases of anesthesia
Drugs
Sedation/tranquilization Induction Pain management Cardiovascular support

Supportive care
Fluid resuscitation Thermal support Positioning

Monitoring

Patient Preparation
IV catheter placement Hemodynamic stabilization Pre-induction monitoring Premedication/sedation Preoxygenation with open mask

Preanesthetic Procedures
ASA I: normal patient

ASA II: with mild systemic disease

ASA III: with systemic disease & limited activity ASA IV: incapacitating systemic disease

Use an individualized patient care plan

Preanesthetic Procedures

Insert and secure IV catheter Prepare perioperative fluids and start infusion Set up monitors for easy connection to patient

Multimodal Anesthesia
Select and administer as indicated:
Tranquilizers or sedatives Opioids or other analgesics

*Administer intravenous and inhalant anesthetics as selected

General
Anesthetics are administered by or under the supervision of a veterinarian on the premises

Ensure Airway Patency

Suitable size,cuffed endotracheal tube Start Oxygen flow from anesthetic unit Connect to endotracheal tube Adjust oxygen flow Add inhalant anesthetic as indicated

Preanesthetic Procedures
Many variables have the potential to influence the response to anesthesia in an individual patient

Perioperative Anesthesia
Maintain appropriate levels of anesthesia
Regularly monitor and record:
Anesthetic depth Pulmonary parameters Cardiovascular parameters

Anesthetic Emergencies

In the event of respiratory or cardiac arrest, the practice team follows a standard procedure for resuscitation directed in each case by a veterinarian based upon the unique patient needs.

Anesthetic Emergencies
Dosages & indications of emergency medications are readily available in chart form

Anesthetic Emergencies
Emergency drugs and equipment are: Readily available Kept in a designated place

Portable
Clearly labeled

Appropriately stocked at all times

Anesthetic Management

Critical Care

Especially challenging in High Risk patients

Helpful Adjunctive Procedures

Local anesthetic nerve block Epidural analgesia Analgesic drug infusion (CRI)

Anesthetic Maintenance by Either:

An oxygen-enriched mixture with the selected inhalant anesthetic Continuous infusion or intermittent doses of injectable anesthetic Combination of injectable or inhalant anesthetics

Circulatory Function Concerns

Hypertension
Increase anesthetic concentration or add additional analgesics

Hypotension
Reduce anesthetic concentration Increase IV fluid rate of administration Administer vasopressors and/or inotropes

Arrhythmias
Diagnose and treat as indicated Reduce incidence during isoflurane or sevoflurane Lidocaine without epinephrine or other antiarrhythmics as necessary

Pulmonary Function Concerns

Oxygen flow rate depends on the breathing system used. Minimal flow rate =10 ml /kg/minute
An additional 500 ml/minute is frequently required

Oxygen saturation (SpO2) >90% End tidal CO2 < 50 mmHg Manual or mechanical IPPV if needed

Recovery: Special Considerations

Continue supplemental oxygen until SpO2 levels are acceptable on room air Extubate when patient can adequately protect airway Provide adequate thermal support Reassess patients pain level and adjust medications as indicated Reapply eye ointment until adequate blink reflex

Provide A Dedicated Recovery Area And Equipment

Patient should be monitored by trained staff Patient support until they return to base line values

Improvements in veterinary anesthesia helps assure better results for the surgical patient

Provided by Charles E. Short, DVM, PhD, ACVAA, ECVAA Emeritus Professor of Anesthesiology & Pain Management, Cornell University
In Consultation with:

Ralph C. Harvey, DVM, MS, Diplomate ACVAA Associate Professor Anesthesiology, University of Tennessee

Prepared using the accreditation standards of the American Animal Hospital Association, Copyright 2012