exam 2 Flashcards
How much of body weight is composed of water?
60%
- 20% extracellular fluid- 5% intravascular, 15% interstitial
- 40% intracellular fluid
Why is edema formation likely during hypoalbuminemia?
-albumin is a determinant of colloid oncotic pressure
What influences fluid movement
- osmosis- dependent on concentration gradients of ions
- plasma proteins and oncotic pressure
- hydrostatic pressure: exerted by fluids due to their weight, antagonizes osmosis during fluid shift and drives fluid outwards
- extracellular fluid movement
Crystalloids
- contain water, electrolytes, non-electrolytes
- can enter all body fluid compartments
- replaces small blood losses at 3:1 volume ratio
- can be isotonic, hypotonic, hypertonic
- types: replacement (balanced) solutions, maintenance solutions
replacement/balanced solutions (crystalloids)
- ringers, lactated ringers, plasma-lyte R (normasol R)
- used to replace body water and electrolytes (diarrhea, vomiting, PU, third space losses, dehydration)
- electrolyte composition similar to ECF
- causes no change in electrolytes
- excessive large volumes dilute proteins
- large volumes cause rapid re-expansion of ECF, but does not remain for long
- normally contains alkalizing agents :lactate, acetate, gluconate
When are replacement/balanced solutions of crystalloids contraindicated?
-large volumes contraindicated in hypoalbuminemia
Maintenance crystalloids
- Plasmalyte M (normasol M) in dextrose 5%
- use in patients stabilized by replacement fluids- or those not taking in adequate amounts to meet daily requirements
- replace daily fluid lose, not for peri-anesthetic
- contain less Na+, more K+- body excretes K+ relatively quicker than Na+
- administered over 24 hrs, avoid large volumes and high infusion rate
Other crystalloids
- physiological saline
- hypertonic saline
- dextrose 5%
When is physiological saline indicated?
- rapid ECF expansion if replacement solution unavailable
- high volumes dilute other electrolytes- careful in patients with electrolyte imbalances
When is hypertonic saline indicated?
- fast onset, short duration, temporary cardiac function improvement (rapid intravascular fluid compartment expansion)
- used to treat cerebral edema if blood brain barrier intact
- limits accumulation of lung fluid
When is Dextrose 5% indicated?
- not used very often
- glucose rapidly metabolized, water is byproduct so used to provide water
- may be used as a component of a maintenance solution
Colloids
- have large molecular weight
- stay in vascular for long- expand and maintain vascular space volume
- replace low volume blood loss at 1:1 volume ratio
- molecular weight too large for capillary pores
- co-administer with 2-3x as much crystalloids to minimize interstitial fluid deficits
- symmetric- hydroxyl-ethyl starch, dextran, gelatin
- natural: whole blood, plasma, albumin
- hb based O2 carrying solutions- oxyglobin
True/False colloids are a long term solution for fluid replacement
-false- don’t carry O2 can cause hypoxemia if not given hemoglobin carrying fluid
HES: hetastarch
- most common
- may alter homeostasis: decrease factor VIII and von Willebrand factor concentrations
- metabolized by serum amylase, eliminated by kidneys
- try to delay use and minimize amounts administered per day
When is HES contraindicated?
- metabolized by serum amylase, eliminated by kidneys
- associated with osmotic nephropathy
- avoid in septic patients
Dextrans
- polymers of glucose
- similar weight to HES
- more hyper-osmotic than plasma
Plasma
- oncotic pull, can increase IVF volume
- albumin= main contributor to oncotic pull
- while still fresh has clotting factors, can be used for treating coagulopathies
Patient comes in with Warfarin toxicity, which fluid can be used to help treat this coagulopathy?
-fresh plasma- clotting factors
You work at a low cost clinic, the doctor would like to perform his routine castrations without the use of fluids to keep the cost low for the client. Why do you advise that this is a shitty idea?
- if under anesthesia patients should be on fluid therapy especially if the procedure is long
- anesthesia can lead to fluid, electrolyte, and acid-base imbalances
- should have a catheter anyways in case of CPR
- correction of deficits due to fasting
- CV support
When is an interosseus catheter indicated?
-small and young animals as well as birds, reptiles, and neonates, very dehydrated or difficult to catheterize
Standard rate for replacement (balanced) crystalloids (e.g. ringers)
10 ml/kg/hr
Cases that would need less fluid
- 3-5 ml/kg/hr
- young animals
- long procedures
- heart failure
- renal disease
Shit! Your patient is hypotensive! What do you do now?
- decrease anesthetic depth
- extra fluid over and above standard rates- crystalloids, colloids (HES)
- if still non-responsive after 2 boluses of fluid- cardioactive drugs
Your patient has started to bleed out (hemorrhage), thankfully it’s minimal (less than 10% blood volume)
- crystalloids (3x volume of blood lost)
- colloids- exact blood volume lost
Patient comes in HBC with >20% BV loss- what do you do?
-give him a goddamn blood transfusion before he dies
Whole blood
- called fresh whole blood up to 8 hrs after collection
- after, called old whole blood- stored at 1-6 C
- RBCs, WBCs, plts, plasma proteins, coagulation factors
- old blood lacks some unstable clotting factors
- can be used up to 21-30 days after collection depending on storage
- indications: active bleeding, hypovolemia, secondary acute hemorrhage
Packed RBC
- contain only RBCs
- PCV about 70%
- ideal for patients with allergic reactions to plasma proteins or with febrile non-hemolytic rxns to WBCs, not common in vet practice
Platelet rich plasma
- harvested from fresh whole blood less than 8 hrs old if not cooled below 20 degrees C
- indicated: severe bleeding in thrombocytopenic patients
- can be further processed to platelet concentrate and pure plasma by centrifugation
pure plasma: fresh or frozen
- plasma protein and all clotting factors except some platelets
- thawed several times only rich in clotting factor VIII, von Willebrand factor, and fibrinogen
- can be viable for more than 1 yr
oxyglobin
- stabilized bovine hemoglobin-based oxygen carrying solution
- treat anemia in dogs and cats
- minimum duration of effect= 24 hrs
- adverse effects: potential for circulatory overload, allergic reactions, temporary discolorations of mucous membranes
challenges of blood sources
-collection, storage, expiration, screening tests
indications of transfusion intra-operatively
-severe hemorrhage
indications of transfusion peri-operatively
- severe acute hemorrhage (usually trauma)
- hypoalbuminemia
- thrombocytopenia
- clotting factor deficiency
Blood transfusion triggers
- acute blood loss >20% volume
- more than 10-15% blood volume loss intraoperatively
- acute anemia: PCV less than 20%
- chronic anemia: PCV less than 15%
- anemia and anesthesia: PCV less than 20%
- consider patients clinical presentation as well: HR elevation, weak pulse, hypotension
Blood loss estimation
- intraoperative blood loss:
- surgical site
- soaked swabs (estimate volume)
- surface
how much blood to administer in acute hemorrhage
- same amount lost
- start slow, check for reactions
- target completion within 4 hrs
how much to administer in anemic hemorrhage
- target pcv
- dogs:25-30%
- cat: at least 20%
empirical doses of blood (mL/kg)
- dogs: 10-40
- cats:5-20
- horses:20-30
- cattle: 10-40
survival times of RBCs
- dogs: 110-120
- cats 75-80
- horses: 140-150
- cattle 140-160
Good practices for blood transfusion
- slowly rewarm blood to 37 C before transfusion
- don’t refreeze
- use one set/unit of blood product
- IV sets should contain in-line filters or syringe filters if injecting from syringe (cats)
- use separate IV port for blood products (Ca+ in lactated ringers will cause blood to clot on contact)
- monitor vitals throughout
- blood typing
Which species is blood typing necessary, which is recommended, which isn’t needed?
- necessary: cats
- recommended: horses and cattle
- not necessary IN FIRST TRANSFUSION for dogs
dog blood groups
- at least 9
- DEA
- 1.1= most common and universal donor, 1.2 is also universal donor
- usually no need for blood typing 1st transfusion- lack alloantibodies
cat blood groups
- 3 major blood groups: A (most), B, AB
- distribution geographically dependent
- have naturally occurring alloantibodies ALWAYS BLOOD TYPE
horse blood groups
- at least 9
- A,C,Q most common
- Aa, Qa most antigenic
- recently pregnant mares carry most antibodies
- geldings and nulliparous mares of same breed are best donors
Monitoring transusion patient
- obtain pre-transfusion baseline readings
- monitor CS intermittently, every 5-10 mins during transfusion
C.S. acute transfusion reactions
-tachycardias, dysrhytmias, hypotension, tachypnea/dyspnea, pyrexia, wheals/uticaria, vomiting, seizures/tremors, CV collapse
adverse effects of transfusing
- allergic/immunological reactions
- circulatory overload
- hypothermia
- citrate-induced hypocalcemia
- bacterial contamination
- transmission of infectious agents
allergic reaction to transfusion
- signs: fever, uticaria, angiodema, pruruitis, tachypnea
- therapy- stop transfusion, diphenhydramine +/- dexamethasone +/- epi, restart transfusion at slower rate
anaphylactic shock due to transfusion
- sudden tachycardia, hypotension, cardiac arrest, collapse
- therapy: stop transfusion OR give epi and dexamethasone
acute hemolysis due to transfusion
- signs: tachypnea, fever, hemoglobinemia, hemoglobinuria, shock
- therapy: stop transfusion, dex, saline diuresis, maintain BP
febrile reaction- non-hemolytic
- signs: temp rise by over 1 C, bradycardia
- therapy: stop transfusion, Dex and Ketoprofen, restart at slower rate in 15 mins
circulatory (volume) overload due to transfusion
- signs: tachypnea, pulmonary edema, polyuria
- therapy: stop transfusion, oxygen supplementation, furosamide, restart transfusion at slower rate, consider diff blood product
hypothermia due to transfusion
- low body temp
- stop transfusion, warm blood, begin external warming
citrate overdose induced hypocalcemia
- signs: arrhythmias, tremors, seizures
- therapy: calcium sals slowly over 20 mins under ECG monitoring
hyperkalemia due to transfusion
- ECG abnormalities
- therapy: stop transfusion, normal saline, dextrose with regular insulin
Canine history needed before anesthesia
- duration of complaint
- current meds: heartworm, diuretics, ACE inhibitors, Ca+ channel blockers, Bets blocker, anti-epileptics
- signs of systemic disease- especially cardiac and pulmonary
- previous blood transfusions
- previous anesthesia (problems or not)
Canine signalment- what you should know about for anesthesia
- age- pediatric/geriatric
- gender- if preggo
- breed- sighthounds- don’t give thiobarbituates, longer recoveries with propofol and alfaxalone, boxers may be sensitive to acepromazine
- brachycephalic airway syndrome- careful with sedatives, small tube, intubation may be difficult, rapid return to conciousness, extended time with O2, extubate late, may have to re-intubate
- small breed- tracheal collapse- avoid excitement, use sedatives, supplemental O2, have longer ETT available
Breed related anesthetic concerns
- cardiomyopathy: dobies, boxers
- sick sinus syndrome: Schnauzers
- Mitral Valve disease: small breeds
- increased vagal tone: brachycephalics, dauchshunds
- vWD- dobies
- hemophilia- GSD
Premedications-anesthetic (dogs)
- usually opiod and sedative IM before catheter
- if IVC present give premeds IV before induction
- choose opiod based on patient and procedures
Which mu agonists are least likely to cause vomiting?
-fentanyl, methadone
When giving H1 antihistamine is indicated for premeds
- diphenhydramine
- when removing mast cell tumor (release histamine when disturbed)
- histamine causes vasodilation and leaky vessels
What drug can be given 30 minutes before opiod to reduce risk of vomiting?
-maropitant- cerenia- NK1 receptor antagonist
This sedative is commonly used as a premed in systemically healthy patients in low doses.
acepromazine
- causes hypotension- especially when followed by inhalant anesthetic
- causes mild to moderate sedation
This premedication should only be used in systemically healthy patients as it cause hypertension, reflex bradycardia, and DECREASED CO
-dexdomitor- causes marked sedation
This sedative is not usually used in healthy dogs, however it may cause sedation in young, old or sick patients as it is CV and respiratory sparing
-benzodiazepines
sedation for aggressive dogs
IM- ketamine, telazol, or alfaxolone should be combined with alpha 2 agonist and opiod
- alpha 2 combos without anesthetic drug may be dangerous
- owner should give informed consent as you prob won’t be able to do pre-anesthetic eval on them
When anticholinergics (antimuscarinics) are indicated
- patients with pre-existing high vagal tone (brachycephalics, opthalamic disease)
- puppies
- specific procedures that may cause vagal stimulation- opthalamic, laryngeal, GI, urogenital
- don’t administer with alpha 2 agonist unless low BP- consider partial reversal of alpha 2 agonist instead
Induction (dogs)- propofol, alfaxalone, etomidate
- titrate to effect
- give slowly- 1/2 calculated dose over 10-15 seconds and evaluate effect
induction (dogs)- ketamine
- high therapeutic index
- may titrate or administer calculated dose over 10-15 seconds in healthy dog
- always give with benzo
- longer onset of action than other induction drugs
intubation of dogs
- relatively easy to intubate- large trachea vs patient size
- use murphy tube
- brachycephalics may be difficult- long soft palate
- advance tube into thoracic inlet only
maintenance- inhalants for dogs
-iso, sevo
maintenance- CRI injectable for dogs
-propofol, alfaxalone, NOT ETOMIDATE
adjunct CRIs for dogs
- opiods (fentanyl most common)
- lidocaine
- ketamine
- benzos
Cardiovascular support for dogs
- IV fluids- blood volume about 90 mL/kg
- balanced, isotonic crystalloids (LRS, plasmalyte- A, Norm-R)
- common rate= 10 mL/kg/hr
How to treat hypotension in dogs
- dopamine, dobutamine, ephedrine
- norepinephrine and vasopression for very sick patients- profound vasoconstriction so titrate carefully
T/F regurgitation is more common in cats
- false- dogs
- large dogs in ortho procedures
Why do we want to prevent regurg in dogs? (other than aspiration)
-esophageal damage
-esophageal stricture is difficult to treat- you may have to euthanize and then LAWSUIT CUZ U SUCK
-
Well shit, your dog just aspirated-what’s next, what do you do to prevent Mrs. Krabs from suing your ass for killing Fluffy Lumpkins
- if regurg occurs:
- postural drainage while still anesthetized (nose down)
- -swab or suction caudal oropharynx before extubation
- -keep cuff inflated or partially inflated for extubation
- -place in sternal ASAP
How could you have prevented Fluffy Lumpkins from aspirating in the first place?
- proper ETT cuff and lubrication
- if high risk: proton pump inhibitors (omeprazole or esomeprazole), prokinetic drugs (metaclopramide or cispride)
What are certain challenges when it comes to anesthetizing cats?
- more difficult to anesthetize, higher mortality
- smaller body size, more difficult to intubate
- more likely to be hypotensive under anesthesia
- differences in drug metabolism- can be more sensitive
relevant anesthetic history: cats
- owners may be less attentive
- cats hide disease well
- cats generally don’t cough except with asthma- difficult to tell heart disease, also difficult because exercise intolerance not appreciable
- outdoor vs indoor important in relation to infectious disease and trauma risk
cat breed considerations for anesthesia
- Maine Coon= HCM- assess for murmur refer to cardiologist if you detect it
Preferred mu agonist opiods for cats
- oxymorphone, methadone- less likely to cause exceitement
- fentanyl
- buprenorphine- good for visceral analgesia at home
What can all opiods cause in cats?
-post-operative hyperthermia
Premeds- sedatives in cats
- acepromazine, dexmedetomidine- higher dose requirements then dogs, use in healthy patients
- dex causes vasoconstriciton- difficult IVC placement
- benzodiazepines don’t cause good sedation, may cause excitement
IM anesthesia- fractious cats
-alfaxalone or ketamine IM combinations will provide immobilization for fractious cats- intubate as soon as laryngeal reflexes lost
“kitty magic”
-ketamine +alpha 2 +opiod
Induction-cats
- chamber or mask not recommended
- propofol (not propofol 28), alfaxalone, etomidate
- Heinz body anemia can result from repeated propofol administration
intubation in cats
- more difficult, cats are special and fragile
- laryngospasm- use lidocaine
- ensure proper anestetic depth before
- can have tracheal damage/tears- SQ emphysema, pneumomediastinum
- don’t overfill cuff
- disconnect from breathing tubes when moving/flipping
Maintenance- cats
- inhalant anesthetics- MAC is higher in cats (iso 1.4-1.6) than dogs and horses
- injectables: propofol, alfaxalone, NOT ETOMIDATE
- adjunct drugs (CRIs)- opiods (fentanyl), ketamine, benzos, NOT LIDOCAINE
Kitty cat complications
- hypotension- common in cats, be careful with IV fluid rate and excessive fluid boluses (can cause fluid overload)-give dopamine
- post-anesthetic cortical blindness-decreased O2 delivery to brain- mouth gags
- blood transfusions- can die always crossmatch
- NSAIDs- renal effects, cats susceptible
Common horse surgeries
-colic
-arthroscopy
-castration
0upper airway
Where to catheterize horse
-usually jugular vein
preanesthetic prep horse
- fast 4-6 hrs, no water at least 2 hrs before
- pull off shoes (or bandage)
- rinse mouth
premeds- alpha 2 for horses
- xylazine- abortion in third trimester of pregnancy
- detomidine
- romifidine
- acepromazine-mild sedative may cause penile prolapse
which drug is the most common opiod analgesic for horses?
butorphanol
-can also use methadone or morphine, more reserved for severe pain
Pre-med analgesia for horses
- alpha 2 agonist
- flunixine meglumine
- meloxicam
- butorphanol
- methadone/morphine
Induction of anesthesia in horse
- muscle relaxant before induction- GGE/gaufinesin
- benzodiazepine: diazepam or midazolam
- ketamine
- thiopentone
Intubation horses
- usually 26 mm diameter
- use mouth gag
- neck extended
What are important positioning considerations in equine sx?
- cushion pressure points: head, shoulders, pelvis, limbs
- stretch and spread apart limbs
- protect eyes from trauma and pressure
- advance limb down to protect radial n
- keep in only one lateral recumbency throughout
Maintenance in horses
- iso, sevo
- large animal circle anesthesia
- mechanical ventilation preferable if over 45 minutes
- use local anesthetic drugs
Maintenance of horse: PIVA
- reduce the use of inhalants
- balanced anesthesia
- reduce CVS adverse effects
- ketamine, medetomidine, lidocaine
maintenance of horse TIVA
- less CV depression
- good analgesia
- less likelihood of movement in response to sx stimlus
- decreased surgical stress
- lower morbidity and mortality
- better recovery
Triple drip
-ketamine, GGE, xylazine
OR (alternative- ketamine, GGE, romifidine)
-top up with intermittent boluses of ketamine or diazepam/midazolam
What should be especially monitored in equine anesthesia
- hypoventilation- IPPV
- hypotension- monitor with ECG lead 1 (base-apex)
- do regular arterial blood gas measurements
special recovery consideration–> horse
- keep in same lateral recumbency as they were during sx
- assisted vs unassisted recovery
equine hypotension
- MAP <70 mmHg, SAP <90 mmHG
- reduce anesthetics, volume rescuscitation, cardioactive drugs (dobutamine, phenylephrine)
equine hypoventilation
- target 35-45 mmHg PetCO2
- mechanical ventilation
Myopathy! important- clinical changes
- myoglobinuria and hyperglobulinemia
- muscle enzymes elevated
- electrolytes
- elevated BUN and CREA
- CBC: inflammatory leukogram
predisposing factors of compartmental myopathy in horse
- muscle and nerve tissue ischemia associated with inadequate perfusion
- heavily muscled horse
- fit/nervous horse
- persistently low MAP (<70 mmHg)
- improper positioning peri-operatively
- prolonged anesthesia
- halothane
signs of compartmental myopathy in horse
- failure to stand on specific muscle group
- muscle feels hard and is severely painful
- myoglobinuria, subsequent renal failure
tx of compartmental myopathy in horse
- symptomatic- fluids, pain management, oxygen radical scavengers, physiotherapy, TLC
- fasciotomy- decompression
Malignant hyperthermia
- genetic
- horses and pigs- mutations in ryanodine gene- excessive calcium release into sarcoplasm
what conditions can promote malignant hyperthermia?
- halothane
- stress
- depolarizing muscle relaxants (succinyl choline)
- improper positioning perioperatively
signs and symptoms of malignant hyperthermia
A large white pig is given halothane for a castration sx, he is now profusely sweating, breathing rapidly, his ECG is showing arythmias, he has prolapsed third eyelids, flared nostrils, contracted masseters as well as muscle rigidity, oh and when he pees his blood is red (myoglobinuria)- what do you suspect? how do you treat? what could have been done to prevent?
- malignant hyperthermia
- prevention: correct positioning and padding, pre-anesthetic dantrolene, maintain normal bp, do not give inhalant anesthetics or depolarizing muscle relaxants such as succinyl choline
- treatment: dantrolene, water/alcohol baths, acepromazine for vasodilation, sodium bicarb for lactic acidosis
What breeds are susceptible to Hyperkalemic periodic paralysis, what is the pathology, what can be due to prevent, how to treat?
- QH and appaloosas
- failure in sodium channels to deactivate- excessive sodium influx and potassium outward flux in muscle cells
- triggered by: transport, stress, sedation, anesthesia
- treatment: increase potassium excretion by: acetazolamide, dextrose, calcium gluconate
What nerves are most susceptible to neuropathy in horses, how to prevent
- facial nerve, radial nerve, spinal malacia
- prevention: correct positioning and padding, remove halter during anesthesia, maintain normal bp, nerve may revitalize once swelling subsides, treat symptomatically
Complications of anesthesia- equine
- nasal edema- place nasal tube until horse stands
- excitement during recovery- more prone to damage to horse and handler- sedate with romifidine/detomidine
What is a very effective sedative in foals?
-benzodiazepine
major differences in donkey anesthesia
- more resistant to sedatives, anesthetics, analgesics- increase dose by 30%
- half life of ketamine shorter
- more sensitive to GGE
Which small animal should be extubated slightly earlier to avoid laryngospasm?
-cats
What to do if regurgitation occurs in small animal patient
- postural drainage- nose low, sternal recumbency
- suction
- swab posterior pharynx with gauze before awakening
- remove ETT with cuff inflated
When is pulse oximeter especially important in small animal patients?
-brachycephalics, upper or lower airway disease, pulmonary pathology
When is blood pressure monitoring especially important in small animal patients?
-hemorrhage, sepsis, hypovolemia
What are considered the most painful surgeries?
-thoracotomy, amputation,e ar resection, pelvic repair, cervical disk repair
What category of pain would an ovariohysterctomy (spay) fall under?
moderate
how to tell pain from opioid dysphoria
- painful patient will quiet with additional opioids
- dysphoric patient will become more distressed with additional opioids
- test: administer short acting opiods e.g. fentanyl and observe effects
alpha 2 agonists used to treat dysphoria and pain
- acepromazine
- benzodiazepine
- butorphanol- maintain some analgesic (opioid antagonist)
short term effects of hypothermia
- increased oxygen demand
- prolonged recovery
- discomfort
long term effect of hypothermia
- delayed healing
- infection
Which of the following should you not use for active warming on your patient?
A. bair hugger
B. heating pad
c. warm water blanket
d. heated cage
bair hugger is one of the most effective methods, HEATING PAD IS DANGEROUS- THERMAL BURNS
Hyperthermia is rare in small animal anesthesia, but when should you be careful about it
-opioid treated cats, MRI in obese furry dogs
most common causes of hypoxemia (cause you know Ambrisko lives for this)
-airway obstruction, hypoventilation, pulmonary pathology (V/Q mismatch)