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Clinical Anesthesia > Diseases > Flashcards

Diseases Flashcards

1
Q

T or F: Dogs being treated with ACE inhibitors and diuretics for CHF can be anesthetized

A

True; animals with untreated CHF should not be anesthetized

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2
Q

What are you hemodynamic goals for anesthetizing patients with mitral valve regurgitation?

A
  • Slight reduction in preload may reduce regurgitant flow
  • Avoid acute increases in afterload—> Vasodilators/most anesthetics reduce afterload
  • Maintain contractility
  • HR can be increased slightly; avoid bradycardia b/c results in long systole and worsens regurg!
  • Rhythm: maintain sinus rhythm
  • Avoid severe tachycardia and hypotension
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3
Q

What are your anesthetic goals for a patient with MR?

A
  • Do not fluid overload patient (no boluses); Should receive lower Na fluids (2.5% Dextrose + half strength LRS) at lower rate
  • avoid sinus bradycardia - don’t be afraid to use anticholinergics
  • maintain myocardial contractility, tx hypotension using beta1 agonist (dobutamine, dopamine)
  • slight vasodilation is acceptable, avoid peripheral vasoconstriction —> don’t use alpha 2’s
  • minimize excitement - increased catecholamine release may cause vasoconstriction
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4
Q

What are some anesthetic considerations for pre-medding a patient with MR?

A
  • Ace: low dose, will reduce afterload and provide sedation/minimize catecholamine-induced arrhythmias
  • Opioids: indicated for painful procedure and maintain contractility; however, may cause sinus bradycardia so can add anticholinergic to premed protocol if high dose used
  • Benzos: produce minimal cardiopulmonary depression, can cause paradoxical excitement, so should be avoided in dogs that are not depressed
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5
Q

What are some anesthetic considerations for induction of a patient with MR?

A
  • Propofol: causes some periph vasodilation, but can depress myocardial contractility, should be given slowly, can add in a benzo
  • Alfaxalone: should be given slowly over 60 seconds, same CV effects as prop
  • Ket-diazepam or Ket-midaz: causes transient sinus tachycardia, will increase BP and CO
  • Etomidate: most heart-friendly; maintains MAP, HR, and CO; however, rough induction (gagging, myoclonus); indicated in patients w/ enlarged heart and show CHF signs
  • Neuroleptanalgesia (diazepam/hydro or diazepam/fentanyl): maintains myocardial function, bradycardia may occur, poor quality induction in non-depressed patients
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6
Q

Which drugs should be avoided in patients with MR?

A
  • Xylazine
  • Medetomidine
  • Dexmed
  • Phenylephrine (vasoconstrictor)
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7
Q

What should be used for maintenance in MR patients?

A

Inhalants; either Iso or Sevo

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8
Q

What are the hemodynamic goals for patients with HCM?

A
  • Maintain preload in cats without CHF
  • Afterload should be increased, if possible
  • Myocardial depression is preferred
  • HR should be within normal range; avoid sinus tachycardia, as it can worsen the LV outflow obstruction
  • Maintain sinus rhythm
  • Avoid severe tachycardia and hypotension
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9
Q

What are some anesthetic considerations you should have in a patient with HCM?

A
  • Adequate diastolic filling can be accomplished by large ventricular volume and sinus rhythm (don’t decrease pre/afterload)
  • Ketamine should be avoided b/c it increases contractility and HR, as well as myocardial oxygen demand
  • Control dyrhythmias prior to pre-medding
  • Minimize stress and excitement b/c of catecholamine release that will increase HR and contractility
  • Beta and Ca channel blockers that patient is being treated with should be maintained up until the day of anesthesia
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10
Q

What are the recommended pre-meds for patients with HCM?

A
  • Opioids: minimal effects on myocardial contractility, preload or afterload; may cause sinus bradycardia, can give w/ glycopyrrolate (not atropine) - less sinus tachycardia
  • Benzos: minimal cardiopulm depression, can be given w/ induction agent IV to minimize risk of excitation
  • Dexmed or medetomidine: shown to eliminate outflow tract obstruction, dexmed can be used for chemical restraint
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11
Q

Which pre-med agent is contraindicated for use in cats with HCM?

A

Ace

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12
Q

What are the recommended induction agents for patients with HCM?

A
  • Propofol: if etomidate not available, used in combo w/ benzo to reduce peripheral vasodilation
  • Etomidate: most heart-friendly agent; best choice if available
  • Neuroleptanalgesia: maintain myocardial function, anticholinergic can be added to combat bradycardia, should only be used in HCM cats that are very depressed
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13
Q

What method of induction should be avoided in HCM cats?

A

Mask induction with sevo or iso b/c of the stress and excitement it causes

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14
Q

What drugs should be avoided in cats with HCM?

A
  • High to moderate doses of ace (pronounced vasodilation)
  • Ketamine (increases ketamine and contractility)
  • Atropine (increases heart rate markedly)
  • Thiopental (arrhythmogenic)
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15
Q

What agents are used for maintenance in an HCM cat?

A
  • Iso or sevo
  • Phenylephrine in cats that develop hypotension - alpha agonist that increases peripheral resistance
    • Dobutamine/dopamine should be avoided
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16
Q

What are the hemodynamic goals for patients with DCM?

A
  • Maintain or reduce preload depending upon severity
  • Avoid increases in afterload
  • Maintain or increase contractility
  • Maintain normal HR
  • Control dysthymias
  • Do not increase myocardial oxygen requirement by avoiding tachycardia and hypotension
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17
Q

What are possible sequela of CKD to make sure are managed accordingly prior to anesthesia?

A
  • Change in BBB leading to drug sensitivity
  • Hypovolemia and dehydration
  • Metabolic acidosis
  • HyperK
  • HyperMg
  • HypoCa
  • Anemia
  • Hypertension but reduced cardiac reserve
  • Susceptibility to vagal-induced bradycardia
18
Q

What are some anesthetic considerations you should have when anesthetizing a patient with CKD?

A
  • The kidney’s high metabolic rate makes it prone to hypoxemia and hypotension
  • Anesthesia works on the RAAS to reduce renal blood flow and redirect away from cortex
    • also causes reduced GFR and renal blood flow —> light planes of anesthesia preserve renal autoregulation
  • minimize stress/excitement
19
Q

What are your anesthetic goals in a patient with CKD?

A
  • Maintain renal blood flow
  • Avoid hypovolemia
  • Avoid renal vasoconstriction
20
Q

What are the recommended premeds for a CKD patient?

A
  • Anticholinergics: no significant effect on renal function, must be given to patients w/ high vagal tone
  • Ace: may minimized sympathetic stimulation, can produce hypotension at high doses but low doses are renoprotective
  • Benzos: no renal effects, minimal cardiopulm effects
  • Opioids: no direct effect on kidneys, antidiuretic effect
21
Q

Why should alpha 2s be avoided in CKD patients?

A

Because they will cause short-term glucosuria and polyuria, and they can cause peripheral vasoconstriction and marked reduction of CO

22
Q

Which drugs should be used for induction of a patient with CKD?

A
  • Propofol: no direct kidney effects, though can cause hypotension, so give slow and with pre-med
  • Thiopental: decreases renal blood flow and GFR in proportion to decrease in BP, can minimize hypotensive effect if given slowly, however, propofol is preferred b/c is more quickly metabolized
  • Etomidate: minimal CV effects, hemolysis risk is a concern in anemic patients
  • Neuroleptanalgesia: fluid therapy is a must d/t antidiuretic effects
23
Q

Why are dissociatives, such as ketamine and tiletamine, not recommended for induction agents in patients with CKD?

A

Because they cause sympathetic stimulation, which causes vasoconstriction, and in turn, decreased renal blood flow; also has prolonged effect in cats b/c is almost exclusively excreted by kidneys

24
Q

Maintenance with inhalants, such as sevo and iso, is recommended over injectables in CKD patients..why?

A
  • Excretion is not dependent on kidneys
  • recovery is faster
  • high concentration of oxygen and ventilation can be supported
25
Q

What drugs should be avoided in CKD patients?

A
  • NSAIDs
  • Alpha 2s
  • Ketamine (cats)
  • Telazol (cats)
26
Q

What are important monitoring principles for anesthetic patients with CKD?

A
  • Blood pressure - manage hypotension by decreasing vaporizer setting, give fluid boluses, and administering positive inotropes (dobutamine preferred)
  • Most important factor = fluid administration
    • ​high rate (20 ml/kg/hr) of IV crystalloids should be administered in patients that do not have CHF, pulm edema or are anuric
    • can initiate active diuresis in those with inadequate urine output using furosemide or mannitol
27
Q

What are you anesthetic considerations for a patient with diabetes mellitus?

A
  • Pre-anesthetic bloodwork should include: fasting BG, ketones, serum electrolytes, BUN, hepatic enzyme levels, creatinine, and acid-base values
  • gentle handling and sending patient home ASAP after procedure
  • shorter fasting times
  • well-regulated at home might become hyperglycemic at the hospital due to stress
28
Q

What are your anesthetic goals for a patient with DM?

A
  • Prevent hypoglycemia
  • Maintain fluid and electrolyte balance
  • Control severe hyperglycemia and prevent ketoacidosis
29
Q

What are some good choices for pre-meds in a patient with DM?

A
  • Low dose Ace
  • Benzos
  • Opioids: when added to either ace or benzos
30
Q

What are good choices for induction agents for patients with DM?

A
  • Propofol: may be best choice b/c short acting and doesn’t have “hangover effect”
  • Alfaxolone: rapid clearance/shorter recovery time
  • Thiopental: may cause further increase in liver enzyme levels
  • Etomidate
  • Neuroleptanalgesia: only in depressed patients; not as good as prop/alfaxolone
31
Q

What agents should be used for maintenance in DM patients?

A

Iso or sevo; though sevo has a quicker recovery time

32
Q

What drugs should be avoided in patients with DM?

A
  • Alpha 2’s (hyperglycemia and hypoinsulinemia)
  • Dissociatives (mild hyperglycemia due to sympathetic stim)
  • Mask induction (stress leading to sympathetic stim)
33
Q

What are some important monitoring principles in patients with DM?

A
  • BG levels should be checked every hour or 30 minutes in unstable patients
    • if >300 mg/dL, regular insulin should be given
    • if <100 mg/dL, increase dextrose infusion rate or bolus 50% dextrose
  • Hypoglycemia is more life threatening during anesthesia than hyperglycemia
  • Oral feeding and routine insulin therapy should resume if possible right after recovery
34
Q

What are some important anesthetic considerations for patients with hepatic insufficiency?

A
  • May be hypoglycemic, so BG should be monitored
  • May be hypoproteinemic, so will be more active (free) form of anesthetic drugs present
  • Hypoalbuminemia may have decreased colloid oncotic pressure, so should use colloids (not crystalloids) for patients with albumin levels < 2.0
  • Run coag panel if patient shows evidence of bleeding tendencies
  • Anesthetic agents will have prolonged effects, so drugs that are reversible, have minimal effect on hepatic blood flow, and have a short duration of action are preferable
35
Q

What are you anesthetic goals in patients with hepatic insufficiency?

A
  • Maintain blood flow to the liver
  • Maintain arterial blood pressure above 60 mmHg
  • Maintain eucapnia and prevent hypoxemia
36
Q

What are the pre med recommendations for patients with hepatic insufficiency?

A
  • Benzos
  • Opioids: reversible, minimal CV effects
37
Q

What pre-med agents should be avoided in patients with hepatic dysfunction?

A
  • Ace: longest duration of action and hepatic dysfunction already causes increased free concentration of drug
  • Alpha 2s: reduce CO, vasoconstriction, sinus bradycardia, and hypotension (reduces blood flow to liver)
38
Q

What are the recommended induction agents to be used in patients with hepatic insufficiency?

A
  • Propofol: has extrahepatic metabolism as well, rapidly eliminated (except in cats)
  • Thiopental: hypoalbuminemia will result in more active form
  • Dissociatives: low doses are fine, except in patients showing CNS signs
  • Etomidate
  • Neuroleptanalgesia
39
Q

What drugs should be used with caution in patients with hepatic insufficiency?

A
  • Ace
  • Alpha 2s
  • Ketamine
  • Thiopental
40
Q

What are some important monitoring considerations in anesthetic patients with hepatic insufficiency?

A
  • BP should be monitored and colloids and positive inotropes should be used if needed
  • Should receive high concentration of O2
  • Eucapnia should be maintained, as hypoventilation will decr hepatic perfusion
  • BG levels should be checked at the end of anesthesia and hours into recovery
  • Hypothermia can further prolong the already longer effects

Clinical Anesthesia (15 decks)

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