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Cognition & Senses - wk 3 > monitoring anesthetic depth and recovery > Flashcards

monitoring anesthetic depth and recovery Flashcards

1
Q

what are the stages of anethesia

A
  1. analgesia
  2. delirium
  3. surgical stage (light, moderate, moderate/deep, deep)
  4. respiratory paralysis
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2
Q

light anesthetic plane

A

imedes procedure from being performed

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3
Q

moderate anesthetic plane

A

surgical plane

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4
Q

deep anesthetic plane

A

patient at risk due to magnitude of undesirable side effects

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5
Q

EEG indication of anesthetic depth

A

supplement not suplant - need to use other skills to asses depth

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6
Q

how to measure response to noxious stimuli

A

somatic response

  • sensory - pain
  • motor - movement

autonomic reponse

  • cardiovascular - increase ABP and HR
  • respiratory - increase RR and TV
  • sudomotor - sweating, tearing
  • ocular - pupil dilation
  • hormonal - stress response
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7
Q

what does response to noxious stimuli depend on

A

stimulus intensity

  • larger intensity = greater response

anesthetic depth

  • relative anesthetic quantity within CNS
  • lighter anesthetic depth = greater response
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8
Q

motor indicators: movement

A
  • movement = somatic response to noxious stimuli
  • light plane: movement
  • moderate to deep plane: no movement
  • relatively objective - purposeful movement vs muscle fasciculation or reflex movement
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9
Q

motor indicators: tone

A
  • MOST anesthetic maintenance agents: anesthetic dept = skeletal muscle relaxation; EXCEPTION: ketamine
  • extra-ocular muscles (ocular globe rotation, nystagmus)
  • masticatory muscles (jaw tone)
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10
Q

eye positon - light plane

A

central eye position (no rotation)

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11
Q

eye position - moderate plane

A

species variability

  • dog, cats, pigs: ventromedial rotation
  • cattle: ventral rotation
  • horse: minimal and unpredictable
  • small ruminants and camelids: no rotation
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12
Q

eye position - deep plane

A

central eye position

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13
Q

eye position exception

A

ketamine - central eye position at all planes

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14
Q

nystagmus

A
  • most useful in horses
  • light plane: large rapid nystagmus
  • moderate to deep plane: absent
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15
Q

jaw tone - light plane

A

strong

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16
Q

jaw tone - moderate to deep

A

loose

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17
Q

jaw tone less useful in patients with:

A
  • narrow TMJ range of motion (horses, ruminants, rabbits, pigs)
  • TMJ disorders
  • well developed masticatory muscles (horses. ruminants. rabbits)
  • large mandibular mass (horses, large ruminants)
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18
Q

reflexes

A
  • anesthetic depth = loss of reflexes
  • palpebral reflex commonly used (species dependent, light - present, moderate/deep - absent)
  • protective airway reflexes also lost under general anesthesia (gag reflexes, swallowing, coughing)
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19
Q

palpebral reflex exceptions

A

species exceptions: horses and camelids

  • light and moderate: present
  • deep: absent

agent exception: ketamine

  • light and modetate: present (all species)
  • deep: absent (all species)
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20
Q

cardiovascular indicators

A

anesthetic depth = cardiovascular depression

  • decreased contractility and systemuc vascular resistance
  • arterial blood pressure as an anesthetic depth indicator
  • low blood pressure suggests TOO deep anesthetic plane
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21
Q

autonomic response to noxious stimuli

cardio indicators

A
  • measurable as increased ABP and HR
  • autonomic responses as an anesthetic depth indicator
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22
Q

blood pressure confounding factors

A
  • choice of anesthetic technique and drugs
  • hypoventilation, hypoxemia
  • anemia, hemorrhage
  • cardiovascular disease
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23
Q

respiratory indicators

A

anesthetic depth = respiratory depression

  • minute ventilation = RR x TV
  • objective assessment (PaCO2 as depth indicator, severe hypoventilation suggests TOO deep)
  • subjective assessment (visual est. - unreliable)
24
Q

autonomic response to noxious stimuli

respiratory indicators

A
  • measurable as increased RR
  • autonomic responses as an anesthetic depth indicator
25
Q

respiratory confounding factors

A
  • noxious stimuli
  • hypercapnia, hypoxemia, hyperthermia
  • agent dependent
  • mechanical ventilation
26
Q

response to noxious stimuli during light plane

summary

A
  • movement (CAUTION)
  • severe tachycardia and hypertension
  • erratic respiratory pattern (patient-ventilator dyssynchrony if on ventilator)
  • sweating and tearing (HORSES0
  • pupil dilation
27
Q

response to noxious stimuli during moderate plane

summary

A
  • NO movement
  • mild to moderate increase in BP, HR, RR
  • relative myosis
28
Q

response to noxious stimuli during deep plane

summary

A
  • NO movement
  • minimal to absent changes in ABP, HR, RR
  • pupil dilation
29
Q

inhaled anesthetics

A
  • anesthetic depth = PCNS (partial pressure in CNS) = PA (partial pressure in alveoli)
  • end-respiratory gases closely represent that of alveolar gas (end-tidal concentration)
30
Q

minimum alveolar concentration

A

measure of relative potency of inhaled anesthetics

31
Q

limitations of MAC as a reference point

A
  • inter-individual (& intra-individual) variability
  • age, systemic disease, pregnancy
  • premedication, body temp
32
Q

when does the recovery period begin

A

when the procedure is finished and all anesthetic drugs have been discontinued

33
Q

steps of recovery

A
  • discontinue all anesthetic drugs
  • move the animal to a dedicated area
  • position the animal in sternal recumbency when possible to facilitate breathing
  • increase O2 flow to prevent hypoxia and facilitate wash-out
  • reversal?
34
Q

when the most common time for small animals (and rabbits) to die

A

the recovery period

35
Q

what are the goals of anesthetic recovery

A
  • creating a safe and quiet environment
  • maintaining cardiovascular function
  • maintaining ventilatory function
  • restoring or maintaining normal temperature
  • providing additional analgesia
36
Q

recovery environment

A

depends on:

  • species
  • location
  • caseload

safe:

  • temperature
  • protection
37
Q

recovery equipment

A
  • oxygen supplementation
  • thermal support
  • induction agents
  • monitoring (adequately trained personnel, patient assessment)
38
Q

patient assessment in recovery

A
  • cardiovascular
  • respiratory
  • temperature
  • pain
39
Q

monitoring cardiovascular function

A
  • mucous membrane color and CRT
  • heart rate (ECG, palpate pulses)
  • blood pressure (doppler monitoring, monitoring, invasive BP)
  • lactate
40
Q

how to support cardiovascular function

A
  • IV fluids
  • positive inotropes (dobutamine, dopamine)
  • vasopressors (dopamine, phenylephrine, norepinephrine)
41
Q

respiratory monitoring

A

ventilation

  • respiratory pattern and effort
  • capnography
  • air flow
  • thoracic ausculation
  • arterial blood gas

oxygenation

  • pulse oximetry
  • arterial blood gas
42
Q

ready to extubate - dogs

A
  • risk of aspiration
  • swallowing consistently-ready to extubate
43
Q

ready to extubate - cats

A
  • risk of laryngospasm and tracheal trauma
  • one swallow or movement
44
Q

ready to extubate - horses

A
  • obligate nasal breathers risk of obstruction is recovery
  • extubate when standing
45
Q

ready to extubate - ruminants

A
  • extreme risk aspiration
  • extubate when chewing and swallowing vigorously
46
Q

procedure and patient considerations

A
  • tracheal collapse
  • pneumonia
  • ventral slot
  • thoracotomy
  • neuromuscular blocking agents
  • upper airway obstruction
47
Q

brachycephalic breeds

A
  • maintain ET tube until totally awake
  • pre/post O2
  • ready to re-intubate
  • increased vagal tone
48
Q

oxygen supplemenation

A
  • young healthy small animals for routine procedures usually don’t need supplemental O2 (hypothermia - shivering - increased O2 consumption)
  • horses may supplement for increased oxygen consumption during recovery
  • if N2O used during anesthesia, wash out system w/ 100% O2 for 5-10 min to prevent diffusion hypoxia
49
Q

dysphoria/emergence delirium

A
  • high doses of opioids (dysphoria)
  • older animals
  • predisposed breeds
  • quick improvement w/ 1-3 mcg/kg naloxone or 0.05-0.1 mg/kg butorphanol
50
Q

pain

A
  • suspicion of insufficient analgesia
  • improves with further analgesia
  • high ABP, fR, and HR: non-specific, elevated in fear, stress, shock, during recovery from anesthesia
  • VAS/DIVAS and composite pain scales
51
Q

if no signs of pain at surgical site, consider the other sources of discomfort:

A
  • full bladder
  • constipation
  • bandage pain
  • joint pain from positioning during surgery
  • other pre-existing source of pain (OA, pancreatitis, etc)
52
Q

prevention and treatment of dysphoria

A

prevention

  • minimize stimuli

treatment

  • time
  • consider reversal (benzodiazepines, opioids)
  • consider sedation (alpha 2 agonists, ace)
53
Q

prolonged recovery

A
  • clearance of inhalant anesthetics (ventilation, duration of anesthesia)
  • clearance of injectable anesthetics (hepatic function, renal function)
  • hypothermia
  • metabolic abnormalities (hypoglycemia, electrolyte disturbances)
  • neurologic abnormalities
54
Q

prolonged recovery treatment

A

rule out:

  • hypothermia
  • hypoglycemia
  • abnormal electrolytes

consider reversing

  • alpha-2 agonist: atipamezole, tolazoline, yohimbine
  • benzodiazepines: flumazenil
  • opioids: butorphanol, nalozone, naltrexone, nalbuphine
55
Q

transfer

A
  • patient signalment and medical condition
  • anesthetic procedure
  • all medications
  • complications
  • current status
  • catheter management
  • contact information

Cognition & Senses - wk 3 (13 decks)

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