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~ualof

SmallAnimal
Anaesthesia and
Analgesia

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Edited by
Chris Seymour
and Robin Gleed
BSAVA Manual of
Small Animal
Anaesthesia
and Analgesia
former/y
Manual of Anaesthesia
for Small Animal Practice
Editors:

Chris Seymour
MA VetMB DVA MRCVS
Forty Hill, Enfield, Middx EN l 4DF

and

Robin Gleed
BVSc DV A DipACYA DipECV A MRCVS
Department of C li nical Sciences,
College of Veterinary Medicine, Cornell University,
Ithaca, NY 14853, USA

Published by:

Bdlish S mall Anima l Veterinary Association


Kingsley House, Church Lane
Shurdington, Cheltenha m
GL51 5TQ, United Kingdom

A Company Limited by Guarantee in England.


Registered Company No. 2837793.
Registered as a Charity.

Copyri ght @ 1999 BSA V A

Ali rights reserved. No part of this publication may be reproduced, stored in a


retrieval system, or transmitted, in fonn or by any means, clectronic, mechanical,
photocopying, recording or otherwise without prior written permission of the
copyright helder.

A catalogue record for titis book is available from the British Library

ISBN 0 905214 48 X

The publishers and contributors cannet take responsibility for information


provided on dosages and me thods of application of dmgs mentioned in this
publication. Details of titis kind must be verified by individual uscrs from the
appropriate literature.

Typeset by: Fusion Design, Fordingbridge, Hampshire, UK

Printed by: Stephens & George, Menhyr Tydfil, Mid Glamorgan, UK - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -


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ii

Other titles in the BSAVA Manuals series:


Manual of Canine and Feline Emergency and Critical Care
Manual of Canine and Feline Gastroenterology
Manual of Canine and Feline Nephrology and Urology
Manual of Canine and Feline Wound Management and Reconstruction
Manual of Canine Behaviour
Manual of Companion Animal Nutrition and Fee ding
Manual of Exotic Pets
Manual of Feline Behaviour
Manual ojOrnamental Fish
Manual of Psittacine Birds
Manual of Raptors, Pigeons and Waterfowl
Manual of Reptiles
Manual of Small Animal Arthrology
Manual of Small Animal Clinical Pathology
Manual of Small Animal Dentis try, 2"d edition
Manual of Small Animal Dermatology
Manual of Small Animal Diagnostic Imaging
Manual of Small Animal Endocrinology, 2"d edition
Manual of Small Animal Fracture Repair and Management
Manual of Small Animal Neurology, 2"d edition
Manual of Small Animal Oncology
Manual of Small Animal Ophthalmology
Manual of Small Animal Reproduction and Neonatology
iii

Contents
List of contributors v

Foreword VII

Preface viii

Part 1 BASIC PRINCIPLES

1 The practice of veterinary anaesthesia and analgesia 3


Ronald S. Jones

2 Preoperative assessment 9
Robin Gleed

3 Postoperative care 15
Daniel Holden

4 Anaesthetic equipment 19
R. Eddie Clutton

5 Patient monitoring 43
Craig Johnson

Part 2 THE PHARMACOLOGICAL BASIS OF ANAESTHESIA AND ANALGESIA

6 Analgesia 59
Avril E. Waterman-Pearson

7 Premedication and sedation 71


Victoria Lukasik

8 Intravenous anaesthetics 87
Jacky Reid and Andrea M. Nolan

9 Inhalant anaesthetics 99
John W. Ludders

10 Neuromuscular blockade 109


Ronald S. Jones

11 Fluid therapy and blood transfusion 119


Paula F. Moon

Part3 ANAESTHETIC MANAGEMENT

12 Ophthalmic surgery 141


Jacqueline C. Brearley

13 Dental and maxillofacial surgery 147


Tanya Duke

14 Cardiopulmonary disease 155


R. Eddie Clutton

15 Thoracic surgery 183


Peter J. Pascoe and Rachel C. Bennett
iv

16 Gastrointestinal and hepatic disease 197


Rachel C. Bennett and Peter J. Pascoe

17 Urogenital disease 211


Avril E. Waterman-Pearson

18 Caesarian section 217


Chris Seymour

19 Endocrine disease 223


Craig Jolmson

20 Neurological disease 231


Jacqueline C. Brearley and Karen Walsh

21 Trauma patients 237


Tanya Duke

22 Paediatric patients 247


Daniel Holden

23 Geriatrie patients 253


Robert E. Meyer

24 Anaesthetic emergencies and complications 257


Ralph C. Harvey

Part4 ANAESTHESIA AND ANALGESIA FOR EXOTIC SPECIES

25 Fish 267
Hamish Rodger

26 Reptiles 271
Dermod Malley

27 Birds 283
Neil A. Forbes

28 Rabbits, rodents and fer rets 295


Paul Flecknell

Index 305
v

Contributors
Rachel Bennett MA VetMB CertV A MRCVS
Department of Veterinary Medicine, University of California- Davis, Davis, CA 95616, USA

Jacqueline C. Brearley MA VetMB PhD DVA DipECVA MRCVS


Animal Health Trust, Lanwades Park, Kentford, Newmarket, Suffolk CB8 7UU

R. Eddie Clutton BVSc DV A DipECVA MRCVS


University of Edinburgh, Easter Bush Veterinary Centre, Easter Bush, Rosiin, Midlothian, EH 25 9RG

Tanya Duke DVM DipACVA


Department of Veterinary Anaesthesiology, Radiology & Surgery, Western College ofVeterinary Medicine,
University of Saskatchewan, Saskatoon, CANADA, S7N 5B4

Paul Flecknell MA VetMB PhD DLAS DipECVA MRCVS


Comparative Biology Centre, The Medical School, University of Newcastle, Framlington Place,
Newcastle-upon-Tyne, NE2 4HH

Neil A. Forbes BVetMed MIBiol CBiol DipECAMS FRCVS


Clockhouse Veterinary Hospital, Wallbridge, Stroud, Glos. GL5 3JD

Robin Gleed BVSc DVA DipACV A DipECVA MRCVS


Department of Clinicat Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA

Ralph C. Harvey DVM MS DipACV A


Department of Small Animal Sciences, University of Tennessee, College of Veterinary Medicine, PO Box
1071, Knoxville, TN 37901-1071, USA

Daniel Holden BVetMed DV A MRCVS


University of Bristol, Department of Veterinary Clinicat Science, Langford House, Langford,
Bristol, BS18 7DU

Craig Johnson BVSc PhD DVA DipECVA MRCA MRCVS


University of Bristol, Department of Clinicat Veterinary Science, Langford House, Langford,
Bristol, BS40 5DU

Ronald S. Jones OBE MVSc DrMedVet DVSc DVA FIBiol DipECVA MRCA FRCVS
University of Liverpool Department of Anaesthesia, University Clin ica! Department, Duncan Building,
Daulby Street, Liverpool L69 3GA

John W. Ludders DVM DipACVA


Department of Clinicat Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA

Victoria M. Lukasik DVM DipACVA


Southwest Veterinary Anaesthesiology, 3340-7 N. Mountain Avenue, Tucson, AZ 85719,
USA and Department of Anesthesiology, Arizona Health Sciences Center, 1501 N. Campbell Avenue,
Tucson, AZ 85724, USA

Dermod Malley BA MVB FRCVS


South Beech Veterinary Surgery, 40 Southend Road, Wickford, Essex, SSll 8DU

RobertE. Meyer DVM DipACV A


Department of Anatomy, Physiology & Radiology, College of Veterinary Medicine,
North Carolina State University, 4700 Hills borough Street, Raleigh, NC 27606, USA

Paula F . Moon DVM DipACVA


Department of Clinicat Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
vi

Andrea M. Nolan MVB PhD DV A


Department of Veterinary Clinicat Studies, University of Glasgow Veterinary School, Bearsden Road,
Bearsden, Glasgow, G61 1QH
Peter Pascoe BVSc PhD DV A DipACVA MRCVS
Department of Veterinary Medicine, University of California- Davis, Davis, CA 95616, USA

Jacky Reid BVMS PhD DV A


Department of Veterinary Clinicat Studies, University of Glasgow Veterinary School, Bearsden Road,
Bearsden, Glasgow, G61 IQH

Hamish D. Rodger BVMS MSc PhD MRCVS


Department of Clinicat Studies, School of Veterinary Medicine, University of Pennsylvania,
New Bolton Center, 382 West Street Road, Kennett Square, PA 19348-1692, USA

Chris Seymour MA VetMB DVA MRCVS


23 Mahon Close, Forty Hill, Enfield, Middx, ENI 4DF

Karen Walsh BVetMed CertVA MRCVS


Animal Health Trust, Lanwades Park, Kentford, Newmarket, Suffolk CB8 7UU

Avril E. Waterman-Pearson PhD BVSc DVA DipECVA MRCA FRCVS


University of Bristol, Department of Clinicat Veterinary Science, Langford House, Langford,
Bristol, BS40 SDT
vii

Foreword

Because of my specialist interest in anaesthesia it gives me particular


pleasure to write the Foreword for the new Manual of Anaesthesia and
Analgesia. This new edition of one of our most popular manuals has been
completely rewritten to encompass a practice-orientated clinicat ap-
proach. The joint Editors have assembled a formidable group of experts
to write individual chapters, with several international contributors. The
subject of analgesia is covered in depth, and in response to changing
trends in pet ownership there is a much expanded section on anaesthesia
of exotic species. Recent innovations in both the pharmacology of new
drugs and the introduction of new equipment are full y discussed.
1 am sure that practitioners will give a big welcome to the section on
anaesthesia in the clinicat setting, in which the regimens appropriate for
different types of surgery are discussed. In addition, the chapter dealing
with the hazards of caesarean section will provide both reassurance and
the answers to the most commonly asked anaesthetic questions.
As with the previous editions 1 am confident that this Manual will be
a bestseller and become part of every practice library. It will undoubtedly
prove of immense value to both veterinary surgeons and nurses alike.

John F.R. Hird


BSAVA President 1998-99
viii

Preface

A sound understanding of general anaesthesia is vital for ali practitioners,


whatever their primary area of expertise. In addition, adequate pain
control after injury, either traumatic or surgical, is one of the most
important responsibilities of ali veterinary surgeons.
This manual, with contributions from a distinguished panel of inter-
national experts, offers the clinician a practical and easily accessible
guide to anaesthesia and analgesia in smali animais. Basic princip les and
pharmacology are clearly explained, followed by anaesthetic manage-
ment in theclinical setting. With increasing specialization in practice and
increased client expectations, the complexity of surgical techniques and
the types of patient they are performed upon have grown a pace. One aim
of this manual, therefore, has been to describe the perioperative manage-
ment of patients with pre-existing pathology and its influence on the
course of anaesthesia. An understanding of these special requirements is
essential for a successful outcome.
Uniquely, the manual includes information on differences between
UK and North American practice. Although the text retains British
Pharmacopoeia names fo r drugs, where these are different from their
North American counterparts the US Pharmacopoeia name is given at
first use in each chapter.
In a multi-author book such as this, there is necessarily material that
is covered more than once. The Editors have decided not to eliminate this
overlap on the grounds that there is value in seeing how different
authorities view similar clinical problems. This approach has also re-
duced the need for extensive cross-referencing between chapters .
The many significant developments in the fields of anaesthesia and
patient monitoring that have occurred since the first edition in 1989 are
described, and there is a substantially expanded section on exotic species.
This manual is primarily aimed at veterinary practitioners and stu-
dents. However, the close involvement of veterinary nurses in the ca re of
anaesthetized patients means that they will also find much of relevance
in this book, particularl y those studying for the RCVS Diploma 111
Advanced Veterinary Nursing.

Chris Seymour, Enfield, Middlesex, UK


Robin Gleed, Ithaca, New York, USA

March 1999
PART ONE

Basic Principles
CHAPTER O N E - - - - - - - - - - - - - - - - - - -

The Practice of Veterinary


Anaesthesia and Analgesia
Ronald S. Jones

INTRODUCTION Hypnosis
Hypnosis is a condition of artificially induced sleep
The origins of veterinary anaesthesia are unclear. It is wl1ich, in animais, is usually produced by drugs. Sorne
recorded, however, that Paracelsus adrninistered ether authorities consider hypnosis to be synonymous with
to chickens in 1540. Henry Hill Hickman adrninistered anaesthesia. Confusion a Iso surrounds hypnosis, as it
carbon dioxide to experimental ani mals and showed th at was originally considered, along with muscle relaxa-
italleviated the pain ofsurgery.ltwasnot unti!Morton's tion and analgesia, to be a component of anaesthesia.
demonstration of the effects of ether in Boston, in 1846,
that its use as an anaesthetic came to the public's Analgesia
attention. In the United Kingdom, ether was first given Analgesia implies a diminished or abolished percep-
to human patients in Dumfries and London. Within a tion of pain, or the relief of pain. If sorne analgesie
year it was being used in cats and dogs. Chloroform was drugs are given in sufficient doses they can produce
discovered a year later and became more popular than anaesthesia.
ether in medical and veterinary anaesthesia. Cocaïne
was used as a local anaesthetic, and its use in animais
was highlighted by Hobday, who published the first TYPES OF ANAESTHESIA
book on veterinary anaesthesia in 1915. This was fol-
lowed by legislation - the Animais Anaesthetics Act, There are two types of anaesthesia: general anaesthe-
1919. In the 1930s there was considerable development sia and local, or regional, anaesthesia.
in barbiturate anaesthesia, with the use of intravenous
pentobarbitone and thiopentone. This was mainly popu- General anaesthesia
larized by Professor J. G. Wright. Atthattime, work was General anaesthetic agents normally produce a con-
a Iso being carried out on extradural (epidural) anaesthe- trolled and reversible intoxication of the CNS of the
sia by Dr G. B. Brook. animal. AU methods of preventing awareness of pain,
In the past 50 years there have been considerable which involve Joss of consciousness and the inability
advances in veterinary anaesthesia, mainly linked to to recall traumatic events from diagnostic or surgical
developments in human medical anaesthesia. These procedures, are referred to as general anaesthesia.
include endotracheal intubation, closed circuit anaes- General anaesthetic agents are given either by inhala-
thesia, the introduction of fluorinated inhalational tion or by injection.
agents e.g. halothane and isoflurane, and new inject-
able agents, e.g. ketamine and propofol for the Inhalational anaesthetics
induction of anaesthesia. One development that This type of general anaesthesia in volves the addition
has been specifie to veterinary anaesthesia is the use of an anaesthetic gas or va pour to the,gases inspired by
of CX:l-adrenoceptor agonist drugs. the animal. The majority of these agents undergo a
minimal amount of metabolism within the animal's
body. Hence the greater part of the inhaled agent is
DEFINITIONS excreted via the lungs in an unchanged state. This
con tri butes to the relatively high degree of safety when
Anaesthesia using this type of anaesthesia. If an overdose does
Anaesthesia was proposed by Oliver Wendell Holmes occur, the animal can be ventilated with oxygen, and
to describe the reversible process of depression of the expired gases can be "vented, which means that
the central nervous system (CNS) with drugs that resuscitation is usually rapid and effective. The term
produce unconsciousness and a reduced or absent minimum alveolar concentration (MAC) is used to
response to noxious stimuli, which the patient does describe the end-tidal concentration of any inhalational
not recall. agent that needs to be given to a population of animais
4 Manual of Small Animal Anaesthesia and Analgesia

to prevent a response to a painful stimulus in 50% of effects o n the CNS or cardiorespiratory system. Toxic
that population. It has been determined for all of the effects occur when large doses ofthe drug are absorbed
commonly used agents, and the value varies from into the circulation from the site of injection.
species to species. Familiarity with titis concept and Local anaesthesia can take a variety of different
the values ena bles inhalational agents to be given with forms:
considerable safety, particularly when non-rebreathing
circuits and accurately calibrated and temperature- Topical application
compensated (Tee) vaporizers are used. T his has limited use and is usually confined to the eye
and mucous membranes of the nasopharynx, larynx,
Injectable anaesthetics penis, vagina, rectum and urethra. Topical anaesthet-
A number of anaestheti c agents s uch as ketam ine can ics are applied as a gel or solution, or by aerosol,
be administered by the subcutaneous, intramuscular dependi ng on the area.
or intravenous routes. In contrast, some agents e.g.
thi opentone, are extreme ly irritant w hen injected by Infiltration
routes other than intravenous. Corn pa red with anaes- This involves the injection of the agent at the s ite of
thetic agents given by the inhalationa l route, those operatio n. Unless the procedure is minor and the
given by injecti on cannot be removed from the body, volume of solution small, local toxicity of the agent
and elimination of these drugs and the cessation of may impair healing.
the ir action depends on detoxifica tion and/or excre-
tion, which is us ually via the bile and/or the urine. Regional anaesthesia
With some drugs, e.g. thiopentone, there is a major T l1is involves the injection of local anaesthetic solu-
redistribution of the drug throughout the body, and tions around a nerve, to produce a temporary sensory
metabo lism is relatively slow. T he safety of inject- and motor blockade.
able agents depends on stri ct control of the dose and
the accurate estimation of the weight of the an imal. Extradural (epidural) ana lgesia
Cons iderable ca re and s kill are a lways req uired w hen T his involves the injecti on of drugs into the spinal
using injectable anaesthetic agents in anima is to canal at the lum bosacral space. lt is normally used in
assess the dose. Altho ugh there are guidelines for the dogs but can be used in cats. The technique has
doses of a li commonl y used agents, those thatare safe undergone a res urgence in popularity in recent years,
and effective in a young hea lthy animal may consti- with the use of severa) agents, such as opioid analge-
tute an overdose in an eider! y and/or s ick anima l. It is s ies, for the production of longer term analgesia.
re lative!y easy to overdose an elderl y o r s ick animal.
Overdose wi th injectable agents can be fata l in the Intravenous r egional anaesthesia
absenceof sim pleeq uipmentforresuscitatio n and the This in volves the injection of a local anaesthetic solu-
administration of oxygen. Recovery from inj ectable tion dista l to the site of a tourniquet on a li mb. Analge-
anaesthesia depends on the kinetic profi le of the drug sia occurs in a few minutes and lasts while the tourniquet
and the mann er in w hich th e drug is dealt with by the occludes the arteria l blood suppl y to the limb.
body. If the drug is rapidly cleared, recovery can
sometimes be as fast as that with an inhalatio nal
agent. One of the ad vantages of injectable anaesthetic LEGAL ASPECTS (UNITED KINGDOM)
techniques is that the amount of anaesthetic agent
given to the patien t is accurately known at any par-
ticul ar ti me. W ith experience of patients ' reactions to In severa! countri.es, including the United Kingdom,
an agent in particular situatio ns, it is possible to there is legis lati on governing the administration of
obtain a fairly accurate forecast of the effects of that anaesthetic agents to animais. This is the Protection
agent in other patients. of Animais (Anaesthetics) Act, 1964, which has a
The use of injectable anaesthetics for maintenance number of min or amendments. T he act s pecifies that
of anaesthes ia is increasing in popularity. T he tech- very few procedures can be carried out on certain
nique usually involves giving an agent by intravenous s pecies with out anaesthesia. Procedures include
infusion, together with supplementary analgesie agents. castratio n under a certain age in sorne species, dock-
This route has the distinct advantage that no potentially ing of ta ils, removal of dewclaws and disbudding of
hazardous substances are exhaled into the envirorunent. calves under 1 week of age.
Several agents that are used for anaesthesia and
Local anaesthesia analgesia in the dog and cat are govem ed by the Mis use
This results from temporary blockade of sensory nerves of Drugs Act, 197 1, and its associated regulations.
and is often accompanied by a concurrent block of Over 100 s ubstances are listed in the Act, and they are
motor nerves. Al! of the commonly availab le local placed in four schedules that relate mainly to their
anaesthetic drugs have the potential to produce toxic potential for misuse by humans. The regulations
The Practice of Veterinary Anaesthesia and Analgesia 5

impose a legal obligation on a ll practitioners prescrib- are explained to the owners. They are not only indicat-
ing and giving controlled drugs. Separate registers ing that they are giving their consent but a iso that they
must be kept for all controlled drugs th at are used and have understood what has been explained to them.
supplied. Veterinary surgeons are required to keep
these drugs in a locked receptacle that can be opened
only by an authorized persan or someone with the AIMS OF ANAESTHESIA
authorized person 's consent. A locked caris notclassed
as a locked receptacle. Generally, the aims of anaesthesia are to:

Duty ofcare Prevent awareness of, and response to, pain


The veterinary surgeon has a duty of care (taken from Provide restraint and immobility of the animal
Halsbury's Laws of England) towards the client: in and relaxation of muscles, when this is required
deciding whether the animal can be safely anaesthe- for a particular procedure
tized; in deciding on the appropriate type of anaesthe- Achieve both of the above without j eopardizing
sia; in the administration of the anaesthetic; and in the life and safety of the animal bef ore, during
consultation with other veterinary surgeons to ensure and after anaesthesia.
that the client is properly advised about the recom-
mended course and any special considerations. The It was considered that a single anaesthetic agent cou id
veterinary surgeon must a iso bring to the task a reason- achieve these ai ms and, occasionally, tlùs is true toda y.
able degree of skill and knowledge and must exercise However, as new agents become available and new
a reasonable degree of care. Failure to do so, which techniques are developed, a combination of agents
results in the death or injury of an animal, gives the with specifie actions is more likely to be used to
owner the right to bring a legal action against the produce safe and relatively trouble-free anaesthesia.
veterinary surgeon for recovery of damages. In recent
years there have been two high profile court cases
involving anaesthetized animais being returned to the ANAESTHETIC RISK
owners before they were full y recovered. Bath animais
subsequently died. The Courts found the veterinary While the mortality in fit healthy cats and dogs is
surgeons negligent. around 1 in 679, it decreases to around 1 in 31 in
animais that have disease (Clarke and Hall, 1990).
Negligence Anaesthesia is an unnatural state, and the induction of
An error of judgement does not necessari !y amount to anaesthesia always carries a risk. The degree of risk
negligence. Wh ether or not the degree of competence, can vary widely and, as indicated above, this should
skill and knowledge has been exercised in any particu- always be explained to owners. Even experienced
lar case is normally tested against what is seen to be anaesthetists sometimes have difficulty in assessing
normal accepted practice. In such a situation, the the risk of a specifie procedure in a particular animal.
veterinary surgeon in general practice will be judged However, there are a number of important factors
against the standard of the good, careful and competent which need to be considered before informing an
practising veterinary surgeon. However, veterinary owner. These are that:
surgeons of specialist or consultant status in anaesthe-
sia will be judged against the standards set by their The s ki il and competence of the anaesthetist
peers. have a pronounced effect on the degree of risk to
There is often confusion between negligence and which a patient is exposed. Good and
disgraceful professional conduct that could lead to comprehensive training is essential, but the art of
disciplinary action by the Royal Colle ge of Veterinary anaesthesia can only be developed with
Surgeons (RCVS). Negligence perse does not amount experience
to disgraceful professional conduct, unless it is so When presented for anaesthesia, the animais'
gross and excessive that it is liable to bring the veteri- state of health has a significant effect on
nary profession into disrepute. It is only then that a outcome. Animais may be young and healthy or
disciplinary action may ensue. old and moribund, or their condition may be
between the two. In addition, animais may be
Consent presented as emergencies from trauma of varying
In every case involving anaesthesia, it is essential to severity. In an attempt to quantify risks, the
ensure that the owners or, in their absence, adult American Society of Ahaesthesiologists has
agents, signa consent form for the anaesthesia. It is not produced five categories:
sufficient for them to just signa blank piece of paper - l. Normal healthy patient with no disease
it is essential that the surgical, or diagnostic, procedure 2. Slight or moderate systenùc disease causing
and the anaesthetic technique and the ir associated risks no obvious incapacity
6 Manual of Small Animal Anaesthesia and Analgesia

3. Slight to moderate systemic disease causing Species and breed of animal: These can influence
mild symptoms, e.g. moderate pyrexia, the choice of technique. Sorne breeds respond
hypovolaemia or anaemia adversely to sorne intravenous agents. Sorne
4. Extreme systemic disease constituting a threat Boxers are sensitive to acepromazine
to life, e.g. toxaemia, uraemia, severe Age and genera l health: These are important
hypovolaemia, cardiac failure influences on the choice of agents and the doses
5. Moribund or dying patients. used. Doses of anaesthetic agents need to be
reduced in both young and elderl y animais. In
White it is accepted that this classification is a useful puppies and kittens of a very young age,
a id, it should be appreciated that it applies only to the inhalational agents are the drugs of choice.
physical state of the patient, and a number of other Such patients are also very susceptible to
factors must be considered in arder to categori ze the hypothermia. Most animais can be
risk fully. anaesthetized relatively safely, provided
The s kill and competence of the surgeon has an adequate preparation is practised. Problems
obvious influence on the anaesthetic risk. Inexperi- with fluid balance s hould be corrected, and
enced surgeons are likely to take longer to carry out a diabetic patients should be stabil ized before
procedure, and to produce greater trauma than more anaes thesia. Even if anaesthesia is deferred for
experienced surgeons. sorne days, it is essential to ensure that patients
The influence of facilities is also important. A well are healthy before anaesthesia
equipped and staffed unit is likely to produce better Site and nature of the surgery: These influence
resu lts than a less organized unit. the choice of technique. Operations on the head
and neck require endotracheal intubation. Special
care must be taken during oral, dental and
CHOICE OF ANAESTHETIC pharyngeal surgery to prevent the accumulation
TECHNIQUE of any material that could be in ha led after
removal of the endotracheal tube. The use of an
A variety of factors influence the choice of a parti cu lar endoscope within the respiratory tract presents
technique. These inc lude: problems because of competition for the airway,
and anaesthetic techniques need to be adapted to
Facilities: If facilities are poor and likely to deal with titis problem
prej udice the outcome of the anaesthetic Use of muscle relaxant drugs. Intermittent
procedure, they s hould not be used. For example, positive-pressure ventilation is required when
a well administered intravenous technique may such drugs are used to provide profound muscle
be much safer than an inhalational agent given relaxation during anaesthetic techniques for
with inferior equipment surgery of the thorax and abdomen or fo r sorne
Ski li and experience of the anaesthetist and orthopaedic procedures
s urgeon: These are extremely important in Anaesthesia fo r Caesarian section: This requires
choosing a technique (particularly noticeable if special techniques because multiple lives are
they are used to working as a team) involved
Facilities for postoperative recovery and care: Examination under anaesthesia: Although this
These will be influenced by whether the animal normally requires only s hort periods of
is to be hospitalized or returned to the owner anaesthesia, considerab le care is still required.
(see legal aspects above). It is important to The old adage that 'there may be minor
ensure that adequate postoperative analgesia is procedures but ne ver minor anaesthetics'
provided certainly applies
Temperament of patient: This can have an Proposed duration of surgery: This must al ways
important influence on the choice of teclmique. In be considered when selecting an anaesthetic
animais of good temperament, a minimum a mount technique. Short procedures can be carried out
of sedative premedication may be required before with a single dose of thiopentone, and slightly
the intravenous induction of anaesthesia. longer ones with multi ple doses of propofol.
Competent assistance in restraint can be of Even under these circumstances, equipment must
extreme value. Sorne cats may be so unruly that be readily available to carry out endotracheal
crush cages or inhalational anaesthetic induction intubation and intermittent positive-pressure
chambers are needed. Vicious dogs may requ ire a ventilation. In situations where procedures are
heavy sedative premedication before anaesthesia, likely to be prolonged, it is important to ensure
which can influence the subsequent doses of that proper inhalational anaesthetic techniques
anaesthetic agents are used.
The Practice of Veterinary Anaesthesia and Analgesia 7

PERSONNEL Administering the selected pre- and


postoperative sedative, analgesie or other agents
The role of veterinary nurses and technicians in Administering prescribed non-incrementai
anaesthesia is currently the subject of debate within anaesthetic agents on the instruction of the
the veterinary profession in the United Kingdom and directing veterinary surgeon
elsewhere. It is weil accepted that both the mainte- Monitoring clinical signs and maintaining an
nance of anaesthetic equipment and preparation for anaesthetic record
anaesthesia can be delegated to veterinary nurses. Maintaining anaesthesia by administering
They also play a major role in the restraint and supplementary incrementai doses of intravenous
management of animais during induction. However, anaesthetic agents or adjusting the delivered
current legal advice to the RCVS indicates that the concentration of anaesthetic agents, under the
induction and maintenance of anaesthesia is an act of direct instruction of the supervising veterinary
veterinary surgery, as defined under the Veterinary surgeon'.
Surgeons Act, 1966.
The current role of the veterinary nurse in veteri-
nary anaesthesia in the United Kingdom is such that: REFERENCE AND FURTHER
' Provided the veterinary surgeon is physically present READING
during anaesthesia and immediate! y available for con- Clarke KW and Hall LW ( 1990) A survey of anaesthesia in s mall animal
sultation, it would be in order for a veterinary nurse, practice: A VA/BSA VA report. Joumal of the Association for
Veterinary Anaesthesia 17, 4-10
wh ose na me is on the list held by the RCVS, to pro vide Hall LW and Clarke KW (199 1) Veterinary Anaesthesia, 'l" edn.
assistance by: Baillière Tindall, London
CHAPTER TWO - - - - - - - - - - - - - - - - - - - -

Preoperative Assessment
Robin Gleed

INTRODUCTION form for this record expedites the process and helps
ens ure that ali of the necessary information is collected
A li patients should be evaluated before undergoing and the appropriate procedures are carried out. The
anaesthesia. This evaluation should be directed to- headings given below may be used as the basis for a
wards the detection and investigation of conditions comprehensive record of the preanaesthetic evaluation.
that may interfere with anaesthesia. It shoul.d not be
restricted to an investigation of the reason for anaes-
theti zing the animal. Necessa rily, it will focus on the HIS TORY
nervous, cardiovascular, pulmonary, he pa tic and re-
nal systems. An accurate preanaesthetic evaluation T he following components of the history are usuall y
helps in appropriate choice of anaesthetic protocol, gathered by interviewing the owner and are based on
forewarns of possible complications and permi ts an those identified by Poffenbarger (199 1).
assessment of risk.
Ideally, preanaesthetic assessment should occur in Signalment
two stages: first, a thorough evaluation 1-7 da ys before The basic details should include species, breed, sex
anaesthesia, giving time for further diagnostic proce- and age of the patient. Verification of the client's
dures that may be needed and for treatment of any address and availability by telephone should also hap-
significant abnormalities that are found; and second, pen at this time. The latter is useful because it is not
an abbreviated evaluation on admission of the patient. unusual to need to communicate with a client white a
For practical reasons, assessment is often carried out in procedure is underway (e.g. to obtain permission for
one stage at the ti me of admission of the patient and euthanasia of an animal with an inoperable tumour)
may, of necessity, be shortened for patients presented and delay at such times is frustrating at best. The
for emergency procedures. patient's unique identifier, for example, clinic number,
The fundamental components of this preanaesthetic should also be recorded.
evaluation are the history and physical examination.
Extensive assessment of blood samples and other Main complaint
diagnostic procedures should be carried out only Although the major goal of the history is to detect any
when indicated by the findings of the history and conditions that may interfere with a normal anaes-
physical examination. thetic, experience suggests that most clients prefer to
A trained veterinary nurse or animal health techni- discuss fi rst the reason for which the anaesthesia is
cian can obtain a satisfactory history and physical ex- being performed, for example, ovariohysterectomy or
amination. Nevertheless, many veterinarians who repair of a fractured femur.
delegate these responsibilities to a nurseftechnician also
feel an obligation to talk in person with the owners of History of the present illness
patients that they are going to anaesthetize. In any case, The severity, onset and duration of relevant clinicat
if the history and physical exarnination reveal some- signs should be determined. This may be important for
thing that may interfere with anaesthesia, veterinarians animais that have recently been traumatized or are
should communicate direct!y with the ir clients. Anaes- vomiting.
thetic rnishaps are a common cause of litigation in both
the UK and the USA. Experience suggests th at most law Medical history
suits and much ill feeling can be forestalled by good This should inelude details of puppy or kitten diseases,
communication with clients before the event. adult illnesses, traumatic injuries and previous surger-
Ali of the results of the preoperative assessment ies. Any adverse responses to previous anaesthetic
should be recorded and stored in the patient's record, episodes, including delayed recovery, should be weil
either in a computer database or on paper. A prepared documented and their causes identified if possible.
10 Manual of Small Animal Anaesthesia and Analgesia

Current health status PHYSICAL EXAMINATION


Apart fro m the main complaint (discussed above), the
animal ' s vaccination status s hould be defined and a The physical examination, comprising observatio n,
record made of ali drugs presentl y being given. palpati on, auscultation and percussio n, enables the
veterinary surgeon to gather information (Poffenbarger,
Systems review 199 1). Most practitioners further develo p their own
This is us ua lly best attempted as a series of neutra! routine for physical examination that encompasses
questio ns worded, if possible, so that they do not ali important organ systems and can be applied to
encourage a specifie response. ali patients. Often this routine starts with a general
o bservation of the patient without disturbin g it,
Genera l followed by measurement of breathing rate, heart rate
and rectal temperature. Patients should then be weighed
Has there been any change in name 's weig ht? for accurate dosing of drugs. An accurate bodyweig ht
Has there been any change in name 's behavio ur? is crucia l for sma ll patients ( <5 kg) where the erro r in
Does name show any signs of pain? If so, where? estimated bodyweig ht is relative!y greater than it is in
larger animais. Thereafter, it is usual to exam ine the
Nervous system patient in orderly fashion, from front to back: mouth,
head , nec k, th o rax, abdo me n and limbs . T he
Has na me ever had seizures? If so, when and preanaesthetic physical examination rarely requires
how frequently? equipment more sophisticated than a set of sca les, a
thermo meter, a stethoscope and a penlight. However,
Cardiopulmonary system a reflex ham mer and a haemostat may he lp in exami-
natio n of reflex and sensory function.
Does name cough or sneeze? If so, when? O rdinari ly the results of the physical examinati on
Does name exercise as usual? are recorded by organ system on a fo rm (e .g. general
appearance, mucous membranes, the nervous, cardio-
Gastrointestinal system vascular, pulmonary, gastrointestinal, genitourinary
and musculoskeletal systems and the integument and
How is name 's appetite? lymph nodes). Each system should be marked as
Has na me 's drin king changed? normal, abno rmal or not examined. A li abnorma l find-
Has there been any diarrhoea or vomiting? ings sho uld be described to the extent possible.
To minimize the chances of procedures being car-
Genitourinary system ried o ut on wrong patients, many large hospitals use
the physical examination at admission as an opportu-
Has na me been spayedfcastrated? If so, when? nity to apply a numbered and named collar or some
Have name 's urinary habits changed? other individual identification system. In such hospi-
Has there been any vaginalfp reputial discharge or tals it is the routine for ali interventions (e.g. adminis-
excessive licking of those a reas? tration of drugs) to be preceded by a check of the
patient's identity. At admissio n, it is a Iso a convention
Musculoskeletal system in many hospitals to put a red collar o n aggressive
animais. This fo rewams anyone who may handle the
Does name seem weak? animal after admission to take special care.
Does name fa vour any leg when walking or T he side of alllaterali zed signs or lesio ns sho uld be
running? clearly recordedduring the physical examination. This
minimizes the possibility of subsequent procedures,
ln tegument for example, sti fie arthroto my, being carried out on the
wrong limb.
Has name been chewing or scratching him/ It is usual in many practices to perform basic blood
herself a lo t? If so, where? tests o n patients about to be anaesthetized. These quick
assessment tests usually include packed cell volume
To reduce the risk of regurgitation and aspiration, (PCV) and total protein (often determined by refracto-
it is us ua l to fast adult dogs and cats for at !east 6 hours meter), blood glucose and blood urea nitrogen concen-
before anaesthesia for elective surgery. Young ani- trations (the last two values often deterrnined by dipstick
mals and very small patients (e.g. many bird species, test). These tests provide usefui baseline data and are not
g uinea pigs) may be fasted for a shorter period or not expensive or time consuming. Extensive blood profi les,
at ali. Admission to the hospital is an appro priate time co nsisting ofbatches of measurements, have been advo-
to ask when the animal last ate and to conf irm that cated for screening patients before anaesthesia. In prac-
instructions for fasting have been followed. tice, such profi les areexpensive for the client and ra rely
Preoperative Assessment 11

detect disease processes that have not previously been intubate. Preparation for maintaining an airway
detected in the history or physical examination. On the by visual placement of an endotracheal tube or
rare occasions when such a disease process is detected tracheostomy should precede administration of
de nova, it is even more unlikely to require modification any anaesthesia-related drugs. These patients
of the anaesthetic technique. Preanaesthetic blood pro- require extra vigilance after extubation in case
files may even do harm because they tend to create 'red airway obstruction occurs.
herrings.' This is because the results of most labora tory
blood tests are given with a normal range for that test. Concurrent drugs
This normal range is usually within ± 2 SD of the mean Typically, drugs that are regularly given should not
from a population of normal animais. This suggests that be discontinued in anticipation of anaesthesia. Oral
1 in 20 normal animais have a measurement for that drugs should not be given in the period between
variable that is outside the normal range. Hence, if 10 anaesthetic premedication and induction of anaesthe-
different variables are measured on a blood sample from sia, because pills may be retained in the pharynx and
a normal animal, it is quite possible that at )east one oesophagus after premedicants have been given. Spe-
variable will be marked as abnormal. Time and clients' cifie drug-related considerations are that:
money may be wasted in investigating this spurious
finding, if it is not recognized as a rnistake in interpreta- Aminoglycoside antibiotics (e.g. gentamicin,
tion. As a general rule, expensive blood testsshould only neomycin) may cause neuromuscular
be un.dertaken when specifically indicated by findings transmission black. In conjunction with in.haled
in the history or physical examination, i.e. to confirm a anaesthetics, this may lead to significantly
finding, to measure the seriousness of a disease process impaired ventilation. Gentamicin in high doses
or to assess the progress of treatment. causes renal disease; hence renal function should
be assessed in patients that have received this
drug for more than 4 or 5 days
PREANAESTHETIC FINDINGS THAT Barbiturates that are being given to treat epilepsy
MAY REQUIRE PARTICULAR should continue to be given on schedule.
ATTENTION Theoretically, these barbiturates could have an
additive effect with general anaesthetics.
Breed-related factors However, they rarely produce a clinically
detectable decrease in anaesthetic requirement and
Miniature Sclmauzers often have sick sinus may be responsible for hepatic enzyme induction
syndrome. This breed should be evaluated by Cotticosteroids given for more than 2 da ys
electrocardiograph before and during anaesthesia suppress release of adrenocorticotrophic
Doberman.n Pinschers often have the coagulation hormone and, hence, may reduce the normal
defect, von Willebrand's disease. Ideally, ali of stress response to surgery and anaesthesia.
these dogs should have von Willebrand's factor Hydrocortisone or dexamethasone should be
activity measured before any surgical given intravenously to any animal that has had
intervention. Buccal mucosal bleeding time glucocorticoid therapy recently (see Chapter 19)
should be measured before surgery; the author Digitalis treatment or treatment with other
prefers to measure this after the patient has been cardiac glycosides is usually best continued
premedicated, but it may be measured after through anaesthesia in patients that have stable
induction of anaesthesia. If the buccal mucosal cardiovascular status
bleeding time is >3 minutes and bleeding is Non-steroidal anti-inflammatory drugs (NSAIDs)
anticipated during surgery, then the patient may are legitimate adjuncts to anaesthesia and pain
be treated with desmopressin acetate. management. In high doses they may displace
Cryoprecipitate, fresh frozen plasma or whole dmgs such as diazepam from protein-binding sites
blood may also be prepared for administration and potentiate their activity by increasing the
(see Chapter 11) concentration of active dmg that is available. This
Greyhounds and other sight hounds have greatly effect is probably of little relevance clinically.
increased susceptibility to thiobarbiturates. This Further details of the use of NSAIDs in the
effect makes inadvisable the use of thiopentone perioperative period may be found in Chapter 6.
in such dogs
Boxers (at )east in the UK) and large breed dogs General body condition
are very susceptible to small doses of Obesity compromises the ~ardiovascular system and
phenothiazine tranquillizers, e.g. acepromazine may cause restriction of ventilatory movement; these
Brachycephalic breeds (e.g. Bull Dog or effects are exacerbated by anaesthesia and recum-
Pekingese) are susceptible to airway obstruction bency. Bath obesity and extreme thinness may inter-
after induction of anaesthesia and are difficult to fere with normal dmg disposition in the body.
12 Manual of Small Animal Anaesthesia and Analgesia

History of recent trauma Renal disease


Animais that have been extensively tra umatized Uraemia increases the sensitiv ity to anaesthetic drugs
(e.g. gunshot, raad traffic accident) within the pre- and should be corrected before anaesthesia whenever
ceding 4 days should be investigated for traumatic possible. Hypoperfusion of the kidney during anaes-
myocarditis . This may warrant e lectrocardiography. thesia may cause ischaemic damage th at is sufficient to
Ventricular premature contractions in such patients induce renal failure in patients with pre-existing sub-
may necessitate de lay of anaesthesia until they re- clinical disease. For this reason, elderly arumals in
solve (this usually occurs within 4 da ys of the trauma particular should be given fluids during anaesthesia
that initiated them) or s pecifie treatment (see Chap- and their cardiovascular function monitored carefully
ters 14 and 21). It should be noted that chest trauma (e.g. with indirect blood pressure) to avoid renal
is not a prerequis ite of traumatic myocarditis and th at hypoperfusion (see Chapter 17).
it can occur when the trauma is apparent! y restricted
to the rear limb. Liver disease
Physical examination of pati.e nts after trauma should Liver disease may prolong the action of anaesthetic
be directed specifically towards detecting common drugs that undergo hepatic metabolism. It may a Iso be
sequelae such as ruptured diaphragm, ruptured urinary associated with secondary conditions, fo r example,
bladder and blood loss. coagulation deficits, hypoproteinaemia and hypogly-
caemia (see Chapter 16).
Respiratory disease
Evidence of respiratory disease in the history and Dia betes
physical examination usually requires further investi- 'Elective surgery on diabetic patients with severe keto-
gation with radiography and, iffeasible, arterial blood acidosis should be delayed to permit regulation of the
gas analysis. Pleural effusion should be drained before diabetic state. Even in regulated diabetic patients,
induction of anaesthesia (see Chapter 14). blood glucose concentration should be measured im-
mediately before anaesthesia (see Chapter 19).
Cardiovascular disease
Cardiac disease is usually of most importance when it Skin disease
is severe enough to restrict exercise tolerance and/or Because of the increased risk of introducing infection
produce severe cardiac dysrhythmias . Pericardia l into the meninges, segmentai anaesthesia/analgesia by
effusion should be drained before anaesthesia. extradural (epidural) or s pinal injection is contraindi-
Hypertrophie cardiomyopathy is quite common in cated if there is pruritus at the site of injection. This is
cats that are 3 to 5 years of age and should be suspected a common problem that precludes lumbosacral injec-
in cats with signs ofh yperthyroidism. It is undoubtedly tion in dogs with flea-induced dermatitis.
an important cause of adverse responses to anaesthesia
in cats but it is notoriously diff icult to detect in its earl y
stages. The electrocardiogram of cats with cardio- ANAESTHETIC RISK
myopathy is often inconclusive, as are chest radio-
graphs; diagnosis and accurate assessment usually The findings of the history, physical examination and
requires echocardiography. Cats with cardiac gallop other investigations should be used to assess the well-
rhythms or murmurs may be poor anaesthetic candi- being of the patient, taking into account ali of the
dates because of thjs disease (see Chapter 14). patient's medical problems and including disturbances
produced by the primary presenting complaint. The
Hypovolaemia, dehydration and anaemia American Society of Anesthesiologists (ASA) has a
Fluid and e lectrolyte deficiencies should be cor- useful scale for formalizing this process (Figure 2.1).
rected before anaesthesia. A decrease in red ce l) The advantage of this scale is that the patient assess-
mass is to lerated better than a decrease in blood ment is summarized by a numerical value, which helps
volume, hence, a PCV of around 20 % may be toler- identify those patients that may warrant special atten-
ated as long as blood volume and cardiac function tion in choice of anaesthetic protocol and in monitor-
are maintained. ing. It should be noted that the ASA scale summarizes
only the patient-related factors that contribute to the
Polydipsia and polyuria risk of anaesthesia. Other factors that contribute to
These signs should be investigated before anaesthesia anaesthetic risk include the type of surgical interven-
because they are commonly associated with conditions tion, the experience of the anaesthetist and surgeon and
that may interfere with anaesthesia such as renal fail- the anaesthetic techniques used (Guarnieri and
ure, diabetes and pyometra. Examination of the vulva Prevoznik, 1992). Emergency anaesthesia usually car-
in bitches, urine analysis, blood glucose measurement ries increased ris k both because of the presumed sever-
and abdominal radiography may be indicated depend- ity of the presenting condition and a Iso because there
ing on the physical examination. is less time for patient evaluation and preparation.
Preoperative Assessment 13

Category Description Examples


I Healthy patient Healthy patient for ovariohysterectomy
II Mild systemic disease with no Local infection, compensated cardiac disease
functionallimitations
III Severe systemic disease with Pyrexia, moderate dehydration or anaemia
functional limitations
IV . Severe systemic disease that is a Uncompensated heart disease
constant threat to !ife
v Moribund patient that is not expected Shock, severe trauma, multiple organ failure
to survive 24 hours with or without
operation
Figure 2.1: American Society ofAnesthesiologists physical statt~s scale. The systemic disease may or may not be the condition
for wltich the patient is undergoing anaesthesia. Emergency cases are classi.fied as category IV and V and are marked by the
addition of an 'E' to the number.
Modifi~dfrom Rossm1d Ti11ker ( 1990) with the permission ofCimrchi/1 Li,·iugs1011e.

The anaesthetic assessment process is also an op- time of admission. This should specify the individual
portunity for communicating with the owner both to who will be responsible for the patient wlùle it is in the
reassure them about anaesthesia and to give them a hospital. It should be noted that such forms do not
realistic appraisal of the risks associated with anaes- provide legal protection for the veterinarian in the
thesia. In a university teaching hospital,< 15 % of dogs event that they do not fulfil their professional obliga-
and cats experienced perianaesthetic complications, tions to their patient and client.
whereas <0.5 % died in the perianaesthetic period
(Gaynor et al., 1999). In private practice, mortality
associated with anaesthesia was 0.1- 0.3% (Clarke and REFERENCES
Hall, 1990; Dodman, 1992). Of course, these average
figures are biased by many things, including the gen- Clarke KW and Hall LW ( 1990) A survey of anaesthesia in smali anjmal
practice: A V A/BSA V A repon. Journal of the Association of
era l health of the population undergoing anaesthesia. Veterinary Anaesthesia 17, 4- 10
The group of patients presented to the university hos- Dodman NH ( 1992) Survey of small animal anesthetic practice in
pital may have included a greater proportion of sick Vermont. Joumal of the Amercian Animal Hospital Association
28,439-445
patients than were presented in private practice. Nev- Gaynor JS, Dunlop CI, Wagner AE, Wenz EM, Golden AEand Denune
ertheless, these data give a baseline from which to WC (1999) Complications and monality associated with anesthesia
in dogs and cats. Journal of the American Animal Hospital
extrapolate the particular risk for each patient. Association 35, 13-17
Guamjeri DM and Prevoznik SJ (1992) Preoperative evaluation. ln:
Introduction to Anesthesia, ed. DE Longnecker and FL Murphy,
PERMISSION FOR ANAESTHESIA pp. 19-30. WB Saunders, Philadelphia
ANDSURGERY Poffenbarger EM ( 1991) The health history. ln: Smali Animal Physical
Diagnosis and Clinicat Procedures, ed. DM McCurnin and EM
Poffenbarger, pp. 6- 15. WB Saunders, Philadelphia
It is wise to obtain permission for anaesthesia and Ross AF and Tin ker JH (1990) Anesthesia risk. ln: Anesthesia, ]'d edn,
surgery on a form, which is signed by the client at the ed. RD Miller, pp. 715-742. Churchill Livingstone, New York
1

1
CHAPTER THREE

Postoperative Care
Daniel Holden

INTRODUCTION Common reasons fo r total o r subtotal airway ob-


struction include:
The primary goal of postoperati ve care is to ensure a
smooth, painless and safe recovery from anaesthesia. Extubation before protective laryngeal reflexes
Monitoring of the patient does not cease when the final have retumed
suture is placed; this is merely the point where the Laryngeal paralysisjoedemajspasm
recovery begins and postoperati ve care is provided. Foreign material (blood, sali va, vomitus, teeth or
The patient should be monitored unt il a full leve! of swabs) obstructing the a irway - especially
conscio usness is present and phys iological variab les common after nose, throat o r dental procedures
have normalized. The leve! of sophisti cati on of moni- Acute palatine, parapharyngeal or
toring depends not only on the severity of the patient's retropharyngeal swelli ngs (air, haematomas,
disease, but a Iso the surgical procedure performed. A extravasated flu id o r over-tight dressings)
more detailed description of monitoring eq uipment occluding the airway
may be found in Chapter 5. Unobserved inha lati on of ali or part of the ETT
The area where recovery takes place should be Brachycephal ic airway o bstruction syndrome.
continuously staffed by personnel who are trained and
experienced in patient monitoring and are not dis- In extreme cases, inspiratory efforts against an
tracted by other tasks. Rapid access to a source of obstructed airway may lead to pulmonary oedema.
oxygen, emergency equipment and drugs s ho uld be Patients with airway obstruction usuall y display vigor-
possible. T he room should be weil ventilated to pre- o us attempts to breathe, with exaggerated thoracic and
vent accum ulation of expired volati le agents but kept abdominal excursions that are often, but not invari-
at a reasonably high ambient temperature to avoid ab ly, accompa nie d by lo ucl s te rto ro us s no ring
radiant heat Joss from recovering patients; individually respirations. Cyanos is or pallo r may be evident, to-
heated cages and heated water blankets should be gether with tachycardia or, in some cases, severe
ava ilable. bradycardia. These patients are sometimes m istaken
as sufferi ng from emergence de lirium (recovery-
associated excitement and distress) and are given
AIRWAY sedatives, us ua lly with disastro us results. In many
cases the patient requ ires oxygen therapy and may
Problems associated with the airway are amo ng the need re-anaesthetizing and intubating to resolve the
most frequently encountered difficulties in the recov- obstructio n (an appropriate ETT and laryngoscope
ery period. Animais sho uld never be left unobserved sho uld be left by the cage of any patient that might
while intubated. In the vast majority of cases, the experience obstruction in the postoperati ve phase).
endotracheal tube (ETT) may be left in place until there The pharyngeal area should be rapidly examined and
is evidence of return of the coug h reflex. Tube removal swabbed clear of debris. Some form of suction appara-
s ho uld be timed to occur at the end of inspiration so th at tus (e.g. 50 m l syringe, three-way tap, urinary catheter)
removal is immediate!y followed by expiration, thereby or postural drainage may be requ ired to remove more
assisting in the removal of debris and secretions from tenacious material from the upper a irway.
the trachea and larynx. Some anaesthetists prefer to
extubate cats early in the recovery peri od to a void the
likelihood of laryngeal spasm and oedema in response BREATHING
to the presence of the tube. O nce the ETT has been
removed, the patient 's neck s hould be gent!y extended M aintenance of adequate ventilatio n in the postopera-
and the tongue drawn forward if possible in orcier to tive period is essential, not only to maintain the elimi-
maintain patency of the airway. natio n of volatile anaesthetic agents, but also to ens ure
16 Manual of Small Arùmal Anaesthesia and Analgesia

adequate oxygenation and elimination of carbon dio x- ciated with anaesthesia. T he drug acts on the peripheral
ide. Deviees designed to measure tidal and minute carotid and aortic chemoreceptors as weil as the respi-
volumes, such as the Wright's respirometer, may be ratory centres in the medu lla, and essentiall y increases
useful to determine whether these variables are ade- the sensitivity to carbon dioxide, a lthough some no n-
quate after anaesthesia (especially if neuromuscular specifie central nervous system stimulant properties
blocking techniques have been employed). In dogs and are a Iso recogni zed. This results in an increase in bath
cats, minute ventilation should exceed 150 ml/ kg; a tidal volume and respiratory rate. White these effects
value of < 100 m l/ kg requires ventilatory support. may be useful in some situations, it should be borne in
Measurement of end-expiratory carbon dioxide con- mind that doxapram is not a s ubstitute for a patent
centration is a lso an effecti ve way of assessing the airway and positive-pressure ventilation with 100 %
adequacy of ventilation; normal values should not oxygen in an unconscious apnoeic patient. The period
exceed 40 mmHg (5.3 kPa). of stimulation of respi ration is usually short, and
Signs of respiratory inadequacy may vary. Respira- overdosage can produce s ide effects su ch as hyperten-
tory rate and apparent tidal volume are usually de- sion, tachycardia and seizures, ali of which may be
creased, although a high rate does not imply that potentially dangerous in an alread y hypoxic animal.
ventilation is adequate. Hypoxia and hypercapnia may Postoperative ventilatory inadequacy may also re-
result in tachycardia, although this may be blunted by s uit from ai rway-associated complications, as pre-
the bradycardie effects of opioids and ~- agonists or by viously described. In these instances signs of airway
hypothermia. Central cyanosis (defined as the presence obstruction us ually predominate, but in mo re deeply
of >5 g/dl of circulating reduced haemoglobin) is a late unconscious patients, apnoea may be the only present-
and unreliable sign ofhypoxia and a notoriously subjec- ing sig n; adequate monitoring is therefore essential.
tive phenomenon. Severe hypoxia can and does occur in Ali patients undergoing surgical procedures of the
the absence of cyanosis. Pulse oximetry may be useful thoracic cavity s hould have an indwelling chest drain
in postoperative monitoring, but the probes are often forpostoperative management. This will allow g raduai
difficult to maintain in position in recovering patients, restoration of intrathoracic pressure and removal of
and reduced peripheral perfusio n due to hypothermia- flu id and air. The chest shou ld be drained every 15-30
or hypovolaemia-induced vasoconstriction may create minutes in the immediate postoperative phase and the
problems in obtaining meaningful readings. volume of air and fluid removed and recorded. Alter-
Postoperative respiratory inadequacy may be due native!y, bottle drains may be used, permitting con-
to a number of factors. If the patient has received tinuous drainage. Failure of the drain may result in
neuromuscular blocking drugs (e.g. pancuronium, pneum othorax, leading to profound hypoventilation.
atracurium), any resid ual respiratory muscle paralysis Further details may be found in Chapter 15.
will result in ineffectual and incoordinated attempts at Postoperative pain of the thoracic or cranial abdomi-
inspiration and potentially severe hypoventilation. nal ca vities may be sufficient to prevent adequate infla-
Residual effects of analgesie and anaesthetic drugs tion of the lungs, leading to hypoventilation, hypoxia
can also produce postoperati ve hypoventilation. Vir- and hypercapnia. A ' multimodal' approach to analgesia
tually ali of the intravenous and volati le anaesthetic should be adopted using opioid, non-opioid and local
agents will obtund respiration to a greater or lesser anaesthetics to redu ce pain to a minimum. Despite their
extent. Alpha-2 agonist drugs s uch as xylazine and respiratory depressant properties, the use of opioids to
medetomidine have profound respiratory depressant re lieve pain associated with the thoracic wall may in fa ct
effects and are commonly used in conjunction with improve venti lation, the analgesia simply allowing
opioid drugs that a iso cause depression of the respira- greater thoracic excursion. In addition, the use of local
tory system. Such depression may last weil into the anaesthetics such as lignocaine (lidocaine) or bupivicaine
postoperative period ifthese agents are being used for to black intercostal nerves in post-thoracotomy patients,
posts urgical analgesia. Altho ugh both of these classes or patients with rib fractures, is to be strongly recom-
of drug have specifie reversa i agents, it sho uld be mended. Local anaesthetics may also be administered
remembered that drug reversa i may also result in loss directly into the pleuralspace, providinganalgesia in not
of analgesia. Patent )..1 -agonist o pioids s uch as fentanyl only the thorax but also the craillai abdomen.
may be reversed, at least in part, using partial agonist Ail of the above factors may occur separa tely or in
drugs such as bupreno rphine to reduce respiratory combination; these problems may also be further
depression wh ile retaining some analgesia. This prac- compounded by the presence of postoperative hypo-
tice is known as sequential analgesia and has gained thermia, which a Iso acts to depress respiration, thereby
substantial popularity in rabbit and rodent anaesthesia delaying the e limination of volatile anaesthetic agents
where fentanyl is used extensively in combination and sig nificantly prolonging recovery. In a debilitated
with fluanisone (see Chapter 28). postsurgical patient, this may be sufficient to cause
Doxapram hydrochloride is used extensively as a life-threatening respiratory insufficiency. Postopera-
respiratory stimulant in neonatal apnoea and in the tive management of hypothermia will be discussed
management of ventila tory fa il ure or inadeq uacy asso- later in this chapter.
Postoperative Care 17

CIRCULATION

Management and monitoring of the circulation during


the postoperative period is important to ensure a rapid
smooth restoration of physiologically normal cardio-
vascular variables. Heart rate and rhythm, pulse rate
and quality, mucous membrane colour and capillary
refill time should ali be regularly and frequently as-
sessed to identify promptly any adverse trends in the
patient's condition. Monitoring of central venous pres-
• . '""·~ \ ' . "' , ''· ~......, ! , . , 1 ::,,.. ' •
sure and mean arterial pressure can be expensive but '
provides accurate and often invaluable information.
The most common postoperative circulatory prob- 1\ -··1·~~~~~~
h··-.1'~-=-~- ..' · ~ .:. ->-.1
lem is hypotension (mean arterial pressure <60 mmHg). Figure 3.1: Use of counterpressure bandaging to control
This may be due to hypotherrnia, a pre-existing disease, infra-abdominal haemorrhage.
surgical or ongoing blood Joss, effects of drugs used
during, or as part of, the anaesthetic, postoperative
dysrhythrnias, inadequate fluid adminis tration or a com- Lack of endogenous heat production due to
bination of these factors. Signs of postoperative hypo- disease, starvation, trauma or age
tension may include delayed recovery, pale mucous Impairment of thermoregulation by drugs,
membranes, prolonged capillary refill tirne, poor pulse disease and trauma
quality, tachycardia, reduced urine output, cold ex- Exposure to cold surfaces or environment during
tremities and reduced central venous pressure. Treal- surgery and anaesthesia
mentis directed atsymptomatic therapy whileattempting Radiant and evaporative heat !osses due to
to establish and remove the underlying cause. Aggres- surgical preparation and tissue exposure
sive intravenous fluid support should be employed Direct delivery of cold dry gases to the lungs
using balanced electrolyte solutions and/or colloids to (bypassing normal warming and humidification
restore pressure and perfusion. The use of hypertonie mechanisms)
saline solutions (4 ml/kg slow bolus of 7% saline) to Further radiant heat !osses during recovery.
manage haemorrhage should be considered (for further
details see Chapter 11). After the initiation of fluid The pathophysiological effects of hypothermia
therapy, the patient should be monitored closely and a re numerous and complex and may result in
frequently for signs of irnprovement or deterioration. hypoventilation, arrhythmogenesis, alterations in
Any obvious sites of bleeding should have pressure substrate metabolism and central nervous system
dressings applied to them. Continued postsurgical haem- impairment. Shivering in the postoperative period
orrhage into the abdominal cavity or retroperitoneal substantially increases oxygen demand at a time
spa ce may be managed successfully with abdominal and when oxygen delivery to the tissues may still be
hindlimb counterpressure bandages to centralize the impaired by the cardiopulmonary depressant effects
circulation (Figure 3.1); these bandages should be left of anaesthesia and other perioperative events. Sup-
on forup to 6 hours and then removed slowly in a caudal plying an oxygen-enriched gas mixture to high-risk
to cranial direction. Continued blood Joss fro m surgi cal patients during recovery from anaesthesia can be
drains (e.g. chestdrains) or into body cavities, should be justified on these grounds alone. Therapy for hypo-
quantified and the fluid analysed for haematocrit and thermia should be aggressive, and various rewarming
total solids. Lasses of fluid with a packed cell volume techniques may be employed. As weil as providing
approaching that of the patient in excess of 10% of the insulation, the ambient temperature should be raised
patients' blood volume should be investigated surgi- (neonatal incubators are ideal for this purpose, and
cally. Although many hypotensive patients may also be ex-hospital models are often available). Warming
hypothermie, care should be taken with rewarrning as deviees such as waterbeds, heat pads and ' hot hands'
the resultant peripheral vasodilation may precipitate a (surgical gloves filled with water and heated in a
hypovolaemic crisis. microwave) should not be applied directly to the
patient, as burns will result. Catheterization and lav-
age of the urinary bladder and colon with warm 0.9%
BODY TEMPERATURE saline can be extremely effective in small patients.
Progress of the patient's temperature should be care-
Sorne degree of heat loss should be anticipated in ali fully monitored to a void over-heating. The best way
anaesthetized patients, but profound hypotherrnia re- to deal with hypothermia is to take sensible measures
mains a common postoperative problem in small ani- to minimize heat Joss during anaesthesia rather than
mals. The causes are numerous and include: trying to rewarm patients during recovery.
18 Manual of Small Animal Anaesthesia and Analgesia

EVIDENCE OF PAIN Willingness to move, eat, drink and interact with


the observer are ail reasonably reliable signs of ade-
The inability to detect postoperati ve pain in an animal on quate analgesia. In the event of uncertainty, pain
the part of the observer does not negate its existence. The should be assumed to be present and an analgesie
ready availability of numerous opioid, non-opioid and administered. Prolongation of recovery from anaes-
local anaesthetic drugs means that the clinician has no thesia due to postoperative opioid administration is
excuse to allow postsurgical pain to go untreated. Be- not usually significant and is not a contraindication
haviour indicating pain in animais is diverse and may for use of these drugs. The perioperative use of non-
vary between species, breeds or even individuals, so steroidal analgesies (either at the ti me of premedica-
assessment of postoperative pain levels should be per- tion or immediate ly a fte r induction) is now
formed by careful observation, noting responses to commonplace in veterinary analgesia, and the pre-
stimuli such as strokingand gentle pressureapplied onto emptive use of opioid analgesies undoubtedly im-
or near the wound. Cats are fa r less likely to vocalize proves the efficacy in the postoperative period.
than dogs in response to a noxious stimulus and so pain Assessment and management of pain is described in
may sometimes be more difficult to detect in this species. greater detail in Chapter 6.
CHAPTER FOUR

Anaesthetic Equipment
R. Eddie Clutton

INTRODUCTION INFUSION CONTROLLERS AND


SYRINGE DRIVERS
The popularity of injectable techniques in veterinary
anaesthesia owes much to the fact that they require Total intravenous anaesthesia maintained by incre-
little eq uipment. However, the depression of upper mentai injections given 'to effect' is undesirable as it
airway reflexes and the hypoventilation th at character- is characterized by fluctuations in the leve! of anaes-
ize many injectable techniques j ustify endotracheal thesia. In contrast, drug infusion produces more sta-
intubation, oxygen (02) enrichmentof inspired gas and ble conditions. Water-solu ble drugs, which do not
intermittent lung inflation. Therefore, practitioners react with the plastic materi al from which ' drip' and
committed to injectable anaesthetics need to under- adminis tration sets are made, can be mi xed and in-
stand how sorn e equipment operates. The advantages fused with crystall oid solutions, e.g. alfentanil,
of inhalation techniques secure their place in campan- vecuronium. However, changes in venous pressure
ion animal anaesthesia despite reliance upon compli- will affect flow and necessitate constant attention to
cated equipment. the drip rate. Infusion control! ers and syringe drivers
deli ver fluids at a pre-set rate irrespecti ve of changes
in venous pressure.
INTRAVENOUSCATHETERS
Infusion controllers
The useof intravenous catheters is warrantee! whether These regulate the volume of fluid passing through a
inhalation or injectable techniques are used. Properly conventional fluid administration set, and are of two
placed, they allow the rapid administration of top-up types: drip meters and volumetrie pumps . In drip
anaesthetic doses and emergency drugs. They also meters, a light sensor s urrounds the drip cham ber and
lower the risk of extravascular injection (which is counts the drips passing through. The fluid tine is
important when irritant drugs are used, when fluids compressee! whenever the drip rate exceeds the pre-set
are infused or when drugs have to be given over leve!. These deviees are sensitive, but do not recogni ze
severa ! minutes). A range of presterili zed polythene, that the volume of fluid per drip depends on the
nylon or teflon intravenous catheters are availab le in diameterofthe drip chamber pipe, and on the hydraulic
various ga uges and lengths . These are s upplied with properties of the fluid itself, i.e. the drip rate, not
an inner stylet or trochar that is necessary for intro- volume delivered, is controlled. In volumetrie pumps
duction. Severa! sizes s hould be available to ca ter for a peristaltic roUer compresses the fluid tine at a rate
the range of animais encountered in c linicat practice. calibrated in ml/min, which is preset by the operator.
Commercially available catheters designee! for hu- Such deviees deliver precise volumes and can be
mans meet a li necessary standards and safety require- programmee! to change the infusion rate after certain
ments and aresatisfactory in most companion animais. ti me periods have elapsed (in recognition of the differ-
Consequently, problems do not result from catheters ent pharmacokinetic properties of different drugs).
perse, but from inappropriate catheteri zation tech- Furthermore, many automatically cease infusion when
nique, e.g. venous trauma, inadvertent arterial cath- a predeterminee! volume has been given, when the
eteri za tion, sepsis. However, in some subjects with administration set becomes occluded or when air bub-
abnormall y resilient s kin, e.g. entire male cats and bles are detected in the tine. However, these deviees
dehydrated animais, the catheterfails to penetra te the are better suited to intensive care situations.
dennis and 'concertinas' back upon the stylet, thus
failing to enter the vein. In such cases, catheters · Syringe drivers
s hould be passed through a small transcutaneous These consist of a chassis in whi ch a drug-filled
inci sion made over the vein with the tip of a number syringe is placed. A mains- or battery-driven e lectric
11 scalpel blade. motor turns a leadscrew which in turn depresses the
20 Manual of Small Animal Anaesthesia and Analgesia

syringe plunger at a constant rate. Drug deli very rate istration of anaesthetics and 0 2 . An improperly used
is altered by varying the mo tor's rate of revolution. anaesthetic machine canjeopardize both patients and
The volume delivered depends on the cross-sectional operating room personnel.
a rea of the syringe. Many syringe dri vers can o nly be Anaesthetic machines possess a basic pattern (Fig-
used with s pecifie makes and sizes of syringe while ure 4.1). The gas flow begins at a carrier gas source (A)
more sophisticated drivers automati cally recognize passes through a pressure gauge (B), a pressure regu-
syringe size and manufacturer. These deviees are lator (C) and a flowmeter assembly (D) and ends at the
robust, simpl e, compact and easy to use, and are ideal commo n gas o utlet (F) where the anaesthetic breathing
when s mall volumes of drug orfluid need to be given, system (ABS) attaches. Vaporizers (E) may be incor-
e.g. to cats. porated within the breathing system (VIC) or, more
Ideal properties of both infusion controllers and usually, downstream fro m the flowmeter assembly
syringe drivers include: reliability, electrical safety, (V OC), as in F ig ure 4.1. Check valves (a), emergency
easeof use,accuracy, robustness, abi lity to use various 0 2 valves (b), law 0 2 alarms (c), nitrous oxide (Np)
types of administration set and syringes, respectively, eut-out deviees (d), overpressure valves (e) and emer-
clear displays and instructions and comprehensive gency air-intake valves (t) are useful options.
alam1 settings and controls. T hese basic components are assembled on a
wheeled chassis, which may carry varying amounts
of accessories.
ANAESTHETIC MACHINES
Components
The essential functions of an anaesthetic machine (in
combination with anaesthetic breathing systems) are to: Gas supply
Gases used in anaesthesia may be stored as liquids or
Deliver safe effective concentratio ns of as compressed gases, either in banks of large cylinders
anaesthetic vapour or in small volume cylinders attached to the anaes-
Deliver 0 2 thetic machine. The choice depends on gas cons ump-
Provide a means of intermittent positive-pressure tion rate, which in turn depends on the practicecaseload.
ventilation (IPPV) during apnoea or Grea ter starage capacities cast more to install, but with
cardiopulmonary arrest time, costs are lower because delivery charges are
Eliminate expired carbon dioxide (C02 ). reduced and larger cylinders cast proportionately Jess
to hire and to fiJI.
Anaesthetic machines a iso act as platforms for ancil-
lary eq uipment li ke monitors and mechanical ventila- Liquid 0 2: The capacity of refrigerated liquid 0 2 flasks
tors and scavenging and suction deviees. U nderstanding probably exceeds the requirements of even the busiest
the constructio n and performance of anaesthetic ma- veterinary facility and they are only practical for large
chines is an important prerequisite for the sa fe adrnin- teaching hospita ls.

Figure 4.1: Anaesthetic machine.


Anaesthetic Equipment 21

UK USA
E F G J E F G
Dimensions 34 x 4 36 x 35 1/2 54 x 7 56 1/2x 9 26 x 4 1/2 51 x 5 1/2 51 x 81/2
Oxygen 680 1360 3400 6800 650 2062 5300
Nitrous oxide 1820 3640 9100 18200 1590 5260 13800
Figure 4. 2: Dimensions (height x outer diameter in inches) and approximate capacity (in litres measured at room temperature
and pressure) fo r various commonly used gas cylinders (adapted fro m Ward, CS, Anaestheti c equipment; physical principles and
maintenance, Baillière Tindall, London, 1975 and Dorsch, J.A. & Dorsch, S.E., Understanding anesthetic equipment ;
construction, care and complicatio ns, Williams and Wilkins, Baltimore, 1984).

Cylinder banks: Vertically standing banks of 3-5 ' J'- strength and safety. They must be stored under specifie
or ' G' -sized cylinders are a convenient way to store conditions (Figure 4.3) . Cylinders storing liquefied
gases in busy small animal practices. Figure 4.2 gives gases, e.g. C0 2 and N2 0, should always be used verti-
the capacity of commonly used cylinders. Two banks cally with the valve uppermost, otherwise liquid will
for each gas (02 and N 20) are desirable; one being in be discharged when the valve is opened.
use, the other in reserve. Switching between banks is Before 0 2 cylinders are connected to the hanger
performed manually or automatically. Gas flows yoke, the cylinder valve should be opened briefly
through a manifold and series of non-retum valves to (' cracked') to flush any dust from the outlet port,
the hospital through pipes inset within the walls. These which may support combustion should transfilling
end in wall-mounted gas-specifie female sockets that occur (see below).
accept gas-specifie male connectors (probes) on flex- Only sufficient force should be used to close a
ible pipes that, in turn, lead to the anaesthetic machine. cylinder valve. Excessive force will damage both valve
Cylinders are painted so that the contents are known, seats and spindles. Cylinder valves and associated
e.g. in the UK: 0 2, black body and white shoulders; equipment must not be lubricated and must be kept
Np, blue; and C0 2, grey (in the USA, oxygen cylin-
ders are green). Pipelines are similarly colour coded,
and the connectors are size- and shape-coded so that Cylinders should be stored:
!ines cannot be accidentally crossed. In the USA, Under cover
threaded medical gas pipe connections should comply Preferably inside
with the Diameter Index Safety System (DISS). Not subjected to extremes of beat or cold
In dry clean well ventilated storage areas
Low-volume cylinders: Cylinder storage requires Separately from industrial and non-medical
space. For most small animal practices low-volume ga ses
'E' cylinders attached to hanger yokes on the anaes-
Cylinders should not be stored:
thetic machine are suitable. However, when gas
Near stocks of combustible material
consumption is high, constant pressure checks
Near sources of heat
and cylinder changing become tedious . Machines
should ho id two cylinders of02 and (optionally) Np. Full and empty cylinders should be stored
The cylinder valve bears hales that correspond with separatel y
pins sited within the hanger yoke. The pin and hole
Full cylinders should be used in strict rotation
pattern is gas specifie, constitutes the pin-indexing
(the earliest date cylinder should be used first)
system and ai ms to prevent connection of the wrong
gas cylinder to the wrong yoke. The system may fail 'F' -sized and larger cylinders should be stored
if pins are broken off by mishandling. For cost- vertically in concrete-floored pens
effectiveness and convenience, anaesthetic machines
'E ' -sized and smaller cylinders should be
should operate principally from piped gases from
stored horizontally
externat stores, and machine-mounted cylinders
should be used as a reserve supply. Emergency services should be advised of the
cylinder store location and the nature of gases
Cylinder safety: Cylinders are filled to high pressures kept there
(at 20°C: 0 2 13,300 kPa (1935 p.s .i.); NP 547 1 kPa Warning notices prohibiting smoking and
(794 p.s.i.)) and so explosions are possible if they are · naked lights should be posted clearly on the
mistreated, e.g. dropped, exposed to heat. Cylinders
storage compound
are submitted to tensile, impact and pressure testing at
regular intervals by the manufacturer to ensure their Figure 4.3: Storage of medical gas cylinders.
22 Manual of Small Animal Anaesthesia and Analgesia

entirely free from carbon-based oils and greases; the pressure that falls with use. Without them, the cylinder
combination ofthese with high-pressure 0 2 may result valve would need to be opened incrementally to main-
in explosion. Similarly, smoking and naked lights tain constant flows. Regula tors also permit sa fe working
must not be allowed within the vicinity of a cylinder or pressures and preventequipmentdamage. Locateddown-
pipe line outlet, or in confined spaces where cylinders stream from the hanger yoke, regulators may be incor-
are stored or used. porated in the yoke itself and be impossible to identify.
Machines holding two cylinders of each gas normally
Check valves have one regulator per cylinder. Gases piped to the
Check valves should be present on machines carrying machine are regulated at source. Deviees incorporating
two or more cylinders of each gas because they: pressure gauges, regulators, flo wmeters and a ' bull-
nose' connector are available for the attachment of
Prevent retrograde gas flow through the inlet pipelines to larger cylinders (from size 'F' upwards).
nipple of vacant hanger yokes when alternative
gas sources (cylinder or piped supply) are in use Flowmeters
Prevent gas transfer between cylinders at high Flowmeters control, measure and indicate the gas
and low pressures flowing around them. On most anaesthetic machines, an
Allow changing of empty cylinders white gas ascending flow of gas s upports a freely moving ' float' -
flows fro m another source. either a bali or bobbin - in a transparent, tapered glass
or plastic tube. The flow rate (in litres per minute),
The check valves are sited within each hanger yoke etched on the tube, is read from the top of bobbins and
assembly immediately downstream from the gas inlet from the equatorof spheres. Flowmeter accuracy is only
nipple, and so are difficult to locate. Confirming their guaranteed between the minimum and maximum
presence and function involves removing the cylinder calibration range. Flowmeters yield false-low readings
from the yoke under test and opening an alternative if dirt, humidity, static electricity or non-vertical posi-
source of the same gas. A hissing sound at the yoke tioning makes the float rub against the tube (slots in the
indicates that the check valve is leaking or absent. rim of bobbins encourage rotation and li mit these prob-
When check val ves are defective or missing, opening lems). Flowmeters are calibrated for single gases, and so
a full new cylinder before closing the old empty one 0 2 flowmeters do not accurately indicate the flow rate of
will result in transfilling, where gas flows from a high N2 0. Consequently, the needle valve control knobs are
pressure cylinder to a low pressure cylinder. The colour and touch coded and bear the na me of the gas.
heat generated by this may cause the old cylinder to Inappropriate settings of the 0 2 and NP flowmeters
explode and soif the check valve function is unknown, re lative to one another can cause hypoxic gas mi xtures
it is safer to close the cylinder that is nearly empty to be delivered. Old anaesthetic machines with func-
before opening the full one. tionally independent flow control knobs are poten-
tially capable of delivering pure (100%) N2 0 , although
Pressure/contents gauge this risk is reduced by having colour-coded, size-coded
The pressure gauge for 0 2 is indispensable as it indi- and touch-coded flowmeter control knobs; on modern
cates the gas volume in the cylinder. This is calculated units in the UK, the 0 2 control is white and is larger and
with Boyle's law (PV = k). An 'E'-sized cylinder has coarser convolutions than other flowmeters. Mod-
contains 680 litres of gas when filled to 13,300 kPa em flowmeter assemblies catering for up to three gases
(1935 p.s.i.) at 20°C. At the same temperature, a (0 2, NP and C02) are available in which N 20 (and
pressure gauge registering 4500 kPa (655 p.s.i.) indi- C02 ) flow is only permitted if the 0 2 supply pressure
cates that only 230 litres remain. The N2 0 pressure exceeds 140 kPa. However, this does not preclude the
ga uge does not act as a contents ga uge; it measures the delivery of hypoxic gas mixtures, which is possible
saturated vapour pressure of gaseous N 20 in equili- when the 0 2 flow control is set too low in relation to
brium with liquid. This remainsconstantuntilallliquid N 20. Therefore, modern anaesthetic machines may
evaporates, after which pressure falls rapidl y. Gas incorporate proport.ioning deviees, which ensure that
volume in N20 cylinders is determined by weighing the lowest 0 2:N20 fl ow ratio is 1:2. The simplest
the cylinder and applying the formula: deviee involves a chain linkage that activates the 0 2
flowmeter whenever the N 20 flow control knob is
Gas present (litres)= (net- tare) weight (in grams) x 22.4/44 switched on. A more complex (and costly) deviee has
two controls : one sets the desired 0 2 percentage (mini-
The tare weight of an NP 'E' cylinder is about 5.8-6.4 kg mum value 33% ); the other controis total gas flow rate
from 1-20 lfmin. A N2 0 eut out intervenes when 0 2
Pressure-reducing valves or regulators supply fai ts .
Pressure-reducing valves (regulators) produce constant Oxygen and N20 mi x freely downstream from the
downstream pressures of 400-800 kPa (60-120 p.s.i.) flowmeter assembly to constitute the carrier gas mix-
and therefore constant gas flow, despite a cylinder ture, which then enters the vaporizer.
Anaesthetic Equipment 23

Vaporizers Ohmeda), output is constant with ti me and unaffected


Breathing the undiluted vapour of most anaesthetics by back pressure, although the dia lied concentration is
would be fatal, because the ir saturated vapour pres- only produced when the liquid anaesthetic is between
sures (SVP) at room temperature produce concentra- l8°C and 35°C. As the temperature of liquid anaes-
tions far in ex cess of th at required for anaesthesia. For thetic falls, a bimetallic strip opens and increases the
example, the SVP for halothane at 20°C is 243 mmHg flow rate of gas entering the vaporization chamber.
and yie lds a concentration given by: Cold ambient temperatures and high gas flow rates
may lower the vaporizer's temperature below l8°C
SVP/barometric pressure* x 100 = 32 % and curtail output, causing difficulty in maintaining
* Nonnally ;1bout 760 nunHg anaesthesia. Under these conditions the vaporizer
requires warming. Dialled and delivered concentra-
This is about 40 times grea ter than its minimal alveolar tions aresimilar at flow rates between0.2 and 151/min.
concentration (MAC) of 0.8 % (which would produce Considerable attention must be pa id to the selection
unresponsiveness in 50 % of animais undergoing of a vaporizer when low flow or closed system anaes-
noxious stimulation). Vaporizers dilute the saturated thesia (see below) is used. Law-resistance vaporizers
vapour of volatile anaesthetics to yield a range of may be used either in the circuit (VIC) or out of circuit
useful (safe) concentrations. Within the vaporizer, (VOC). Plenum vaporizers can only be positioned
carrier gases flow either through a bypass channel VOC. In low flow or closed systems Mark Il, or
or are diverted into a vaporization chamber, which preferably Mark III, Fluotecs calibrated to 8% (rather
contains anaesthetic vapour at its SVP. Here, carrier th an 5%) are useful. However, discrepancies between
gases and anaesthetic vapour mix before rejoining dia lied and output concentrations are high at low flow
gases flowing through the bypass channel. The deli- rates in some vaporizers, so a performance graph must
vered concentration ( %) of anaesthetic is altered by be consulted. The Mark II Fluotec produces very high
turning the control spindle. This action changes the concentrations at flow rates below 4ljmin and must be
ratio of gas entering the vaporization chamber com- used with caution.
pared with that flowing down the bypass channel. Vaporizers are agent specifie. Filling a vaporizer with
Vaporizers are classif ied according to the mecha- the wrong anaesthetic can be prevented by keyed filling
nism causing gas to flow through them. Gases flow ports - the key-index vaporizer filling system. The
through plenum deviees because the anaesthetic keyed filling ports accepta key-ended tube that attaches
machine generates a positive pressure upstream from on ly to the cotTesponding anaesthetic bottle. Used prop-
the vaporizer. In draw-over vaporizers, gases flow erly, the system also assists in controlling pollution
because a downstream negative pressure is generated because the vaporizer can be filled without spi liage.
by the subject's inspiratory effort. In order that this Vaporizers must always be kept in an upright
does not restrictspontaneous ventilation, these deviees position. If they are tilted, liquid anaesthetic may flow
must offer minimal resistance to gas flow. Conse- into the bypass ch amber and expose the next patient to
quently these deviees are a Iso known as law-resistance very high levels of anaesthetic va pour.
vaporizers.
Draw-over or low-resistance vaporizers: Law-resist-
Uncalibrated vaporizers: The Boyle bottle is a sim- ance vaporizers are located within the circuit either to
ple, inexpensive and easily maintained plenum va- facilitate low flow techniques orto confer portability
porizer. However, output concentrations are not to units designed for emergency field use in humans.
defined, drift despite constant control settings and They are found in the Komesaroff and Stephens '
fall as liquid anaesthetic cools or as flow rates in- anaesthetic machines described below. They are sim-
crease over 12- 25 1/min. Output increases if flow ply constructed, inexpensive and offer little resistance
rates are reduced, but increases with increasing flow, to breathing, but are relatively inaccurate.
up to a point. High concentrations are also delivered
when the vaporizer is agitated, temperatures rise or Checking plenum vaporizers before use
back pressure, caused by IPPV, is unchecked and Before turning on the flowmeter control knobs the
forces downstream gas tore-enter the vaporizer. This vaporizers should be checked to ensure they contain
effect is greatest at low flow rates. enough liquid anaesthetic, that the control spindle
turns smoothly and that the filling port is tightly closed.
Calibrated vaporizers: Anaesthetic concentration from If the anaesthetic machine incorporates a pressure-
'tee' (temperature compensated) and other calibrated reliefvalve (see below), the_yaporizer can be tested for
vaporizers is similar to that selected on the di al of the leaks: the control spindle should be set at 0 %, the 0 2
spindle, provided that gas flow through the vaporizer flowmeter control knob set at, e.g. 8 ljmin, and the
and the temperature of liquid anaesthetic are within common gas outlet occluded. There should be no leak
ranges specifie for the model. In Mark III tees, e.g. from any vaporizer fittings, and the flowmeter bobbin
Fluotec (halothane; Ohmeda) and Fortec (isoflurane; should drop.
24 Manual of Small Arùmal Anaesthesia and Analgesia

Back bar respond immediately whenever the alarm is heard.


The series of semi-permanent fixtures that results On sorne machines, N 20 flows through the flowmeter
when flowmeters and (out of circuit) vaporizers are and activates a whistle, but is exhausted safely up-
joined by tapered cagemount connectors and attached stream from the common gas outlet.
to a back bar, makes servicing individual components
difficult. Systemssuch as the ' Selectatec SM' (Ohmeda) Emergency air-intake valve
manifold are more useful as they allow rapid attach- This opens wh en gas flow from the machine ceases and
ment or removal of vaporizers for refilling out of the allows animais to breathe room air unti l flow is re-
operating room, servicing and rewarming. By accom- stored. Valve action should be audible, indicating the
modating up to titree vaporizers, a range of volatile patient 's inspiratory effort. The presence of this deviee
agents may be available. Most modern anaesthetic is confirmed by attaching a pipe to the common gas
machines are equipped with a system that prevents outlet and applying suction.
more than one vaporizer at a time from being turned on
(a double exclusion system). Overpressure valve
Excessive pressures downstream from the common
Common gas outlet gas outlet open titis valve and sound an alarm. The
This connects the anaesthetic machine to breathing deviee is useful for testing breathing systems for leaks;
system connectors, ventilators or 0 2 supply deviees. To its presence is confirmed by occluding the common
meet these roles the outlet must be dual tapered, with a gas outlet while pressing the 0 2 bypass valve.
22 mm outer male connector (to British Standard) and Overpressure and emergency air-intake valves are
15 mm inner female connecter. A swivel conunon gas often constructed as a single attachment.
outlet (e.g. Cardiff swivel) is useful because it reduces
the need to move machines, facilitates circuit position- Miscellaneous accessories
mg and reduces the risk of hoses kinking. Useful accessories with anaesthetic machines include:

Oxygen flush, bypass or purge valve Stainless steel work trays


The 0 2 flush, bypass or purge valve receives 0 2 from An eye-level monitor she lf
the pipeline inlet or cylinder regulator but bypasses Cabinets fo r equipment
the vapori zer. It is used to provide 0 2 in emergency Circuit hooks
situations and may have a Jock-on facility. Wh en acti- Large-diameter castor wheels with brakes
vated, high non-metered flo w rates of pure 0 2 are (desirable on hospital-based machines)
directed to the common gas outlet at rates of 35-60 An adjustable plinth.
1/min. The deviee is also used to flush anaesthetic
from breathing systems before the patient is discon-
nected from the machine, thus lowering pollution. Types of anaesthetic machines
The 0 2 flush valve can be inadvertently activated by
components of the breathing system when the system Purpose-built machines for small animais
is in certain positions. These often have circle breatlling systems specially
built on. The macllines, but not the breathing systems,
Low 0 2 warning deviees are suitable for birds, small mammals and companion
Low 0 2 warn ing deviees are very important on veteri- animais . However, they often Jack the waming and
nary anaesthetic machines as it is not always possible fail-safe deviees required in human anaesthesia.
to monitor gas delivery continuously. Idea lly, fa lling
0 2 supplies should curtail N 20 (and C0 2) flow and Ex-human hospital machines
s imultaneously sound an alarm. (As with ali safety Usually, these are sophisticated and more like ly to
deviees, this a larm should be gas driven and not have the safety features listed above. They are Jess
require batteries or an electrical supply.) The warning expensive than purpose-built small animal models
system present on a machine is tested by switching on although service arrangements may be difficult to
both 0 2 and N 20 sources, opening the flowmeter negotiate and components may be obsolete.
control knobs to give nominal flow rates of 2 and 4
1/min, respectively, and then closing the 0 2 cylinder Unspecified or improvized equipment
(or other 0 2 source). The NP and 0 2 fl ow indicators Safe anaesthesia is possible with an assembly of com-
should fa li simultaneously and an alarm sound (either patible basic components as long as the specifications
intermittently or, preferably, continuously). It is im- of each component are known, they function, and they
portant to establish whether NP flow continues are connected correct! y. Components may be salvaged
through the common gas outlet white the alarm sounds from old machines or bought as new. Combinations of
or is vented e lsewhere; if, as on old or defective basic components mounted on a portable chassis are
machines, the former is the case, the operator must available. In machines for unspecified use, flowmeter
Anaesthetic Equipment 25

and vaporizer performance must cover the needs of the 10. Check the vaporizer (as above)
species to be anaesthetized. Compactness is useful 11 . Check overpressure and emergency air-intake
where space is limited and mobility not required. valves (as above).

Vaporizer in circuit machines (This routine may need to be modified if the anaes-
These are circle breathing systems with one or more thetic machine is connected to a central gas supply.)
law-resistance vaporizers positioned within the breath-
ing system, e.g. Stephens' or Komesaroff models or Shutting down the anaesthetic machine
the Mini -Kom (Kruuse) . Theiroperation requiressome On completion of surgery, the cylinders should be
practice but, once mastered, the systems are safe and checked for content and relabelled. (If present, the N20
easy to use, and because low 0 2 flow rates are used they probe should be removed from the wall socket and the
are very economical to operate. The Komesaroff an- pipe neatly coiled.) The 0 2 flowmeter control knob
aesthetic machine consists of an 0 2 cylinder, a pres- should be opened to produce a flow rate of2ljmin. The
sure-reducing valve and a flo wmeter attached to a N 20 cylindervalve(s) should then be closed and the Np
circle breathing system, which incorporates two in- flowmeter turned on until ali flow of the gas ceases,
circuit vaporizers for halothane and methoxyflurane. when it should be closed again. If 0 2 supply pipes are
The system is portable (weighing about 15 kg) and its present, they should be disconnected, the 0 2 cylinders
design combines the advantages of inhalation anaes- closed' and the02 flush valveactivated until no pressure
thesia while minimizing atmospheric pollution. The registerson the pressure gauge. Machinesurfacesshould
Stephens' anaesthetic machine is similar in design but then be wiped with antiseptic.
incorpora tes a single in-circuit vaporizer and requires
a non-integral 0 2 supply and pressure regulator. The
system is compact and readily adapted for use with ANAESTHETIC BREATHING
halothane, methoxyflurane or isoflurane. The sys- SYSTEMS
tem 's effici ency redu ces costs when ex pensive anaes-
thetics, e.g. isoflurane, are used. Anaesthetic breathing systems connect the anaes-
thetic machine to the connector for the endotracheal
Checking machines before use tube (ETT) or mas k, and they convey anaesthetic
The anaesthetic machine should receive a major cheçk vapour to the patient. They are used during both
at the beginning of each working day and a minor injectable and inhalational anaesthesia to carry 0 2
check after each use. To ensu·re no parts of the test are and to allow intermittent Jung inflation. Improper
omitted a list should be attached to the machine: selection of a system, its misuse or circuit malfunc-
tion may jeopardize patient safety. Because each
1. Ensure flow control valves are turned off circuit has advantages (and disadvantages) in differ-
2. Ensure cylinders are closed and fitted securely ent circumstances, a range should be available to
on the hanger yolk cover ali potential clinical s ituations.
3. Press the 0 2 flush valve until no gas flows from
the common gas outlet Factors influencing selection of a
4. Check that flowmeters and pressure gauges are breathing system
at zero
5. Open the 0 2 cylinder valve (slowly, Resistance
anticlockwise) and observe the registered Anaesthetized animais hypoventilate when there is
pressure. Open then close the 0 2 flowmeter increased resistance to inspiratory and expiratory
control valve to ensure smooth function. Press flow, although animais that are lightly anaesthetized
the 0 2 flush valve. (On machines that carry a may overcome this at the cost of increased work of
second 0 2 cylinder, the tested cylinder should be breathing. Resistance stems from circuit geometry
closed first and the test repeated on the second (:valves, absorbent canisters, constrictions and hose
cylinder) tortuosity) and hose length. The most important con-
6. Label the cylinders either ' in use' or 'full ' tributor to resistance is hose radius; halving the radius
depending on registered pressure increases resistance to gas flow 16-fold. Selection of
7. Replace cylinders with little remaining gas a breathing system is normally based on the patient's
8. Open the 0 2 cylinder that is in use and set the 0 2 bodyweight because larger (heavier) animais are able
flowmeter control knob at 2 1/min. Examine the to overcorrie resistance (lightweight animais are a iso
status of the N20 cylinders as in step 5. Label the Jess able to cope with mechanical dead space). How~
N20 cylinders ever, the limitations of this criterion must be appreci-
9. Set the N2 0 flow control knob at 4 1/min then ated; a fit dog weighing 5 kg may tol.erate res istance
turn off the 0 2 supply; ensure low 0 2 warning that would compromise an obese, older myasthenie
deviee operates (see above) animal weighing 20 kg.
26 Manual of Small Animal Anaesthesia and Analgesia

Species Respiratory rate* Tidal volume* Minute volume* Oxygen consumptiont


(breaths/min) (ml/kg) (ml/kg/min) (ml/kg/min)
Dogs (> 30 kg) 15-20 12- 15 150-250 5.8
(< 30 kg) 20-30 16-20 200-300 6.2
Cats 20-30 7-9 180-380 7.3
Figure 4.4: Respiratory variables in companion animais. *During surgery,jactors like pain, pyrexia and light versus deep
anaesthesia will affectthese values. tOxygen co11sumptioll depends on factors related lO metabolic rate: age, temperature,
tltyroid status, drugs, muscle tone and response to surgery.

Controlled versus spontaneous ventilation and increase pollution and wastage of volatile agents
Controlled ventilation overcomes most of the prob- and so reduce efficiency.
lems of resistance to spontaneous breathing and re-
duces the work of breathing. It is mandatory during Mechanical dead space
thoracotomy, when animais hypoventilate, and during Mechanical or apparatus dead space accommodates
the use of neuromuscular bloclcing agents. The gas gas, which is re-inspired at every breath butwhich does
fl ow requirements of the Magill and Lack breathing not participate in gas exchange. Acting as an extension
systems become uneconornically high during IPPV. of the animal 's anatomical dead spa ce, it is recognized
as the volume between the incisor arcade (rostral li mit
Rebrea thing versus non-rebreathing of anatomical dead space) and th at part of the breatlùng
Rebreathing is the re-inhalation of expired breath. system where inspired and expired gas streams di vide
Expi red gas is wa rmer, more moist and higher in C0 2 (Figure 4.5). It redu ces the portion of inspired fresh gas
but lower in 0 2 and anaesthetic vapour than fresh reaching alveoli and, in the absence of increased minute
(inspired) gas from the machine. Total rebreathing ventilation, causes hypoventilation.
results in undesirable accumulation of C0 2 • Partial
rebreathing describes re-inspiration of breath from Circuit drag
wh ich C0 2 has been removed. This is advantageous Heavy hases, valves and absorbent canisters create
(heat and water va peur are retained) and safe, drag and facilitate inadvertent extubation or circuit
providi ng 0 2 and a naestheti c are reple n ished. disconnection whenanimals moveorare moved. Light-
Partial rebreathing is useful in animais at ris k from weight plastic hoses without drag (or rigidity) are
hypothermia and those with certain types of tracheo- desirable in small subjects, e.g. birds. Valves and
bronchial disease. Circle and to-and-fro systems multiple hoses adjacent to patients contribute to drag;
that allow partial rebreathing a re described as coaxial (tube within a tube) systems have neither, so
rebreathing systems. are useful in very small animais.

Fresh gas flow requirements Ease of maintenance and sterilization


In rebreathing systems, gas flow from the machine Disposable lightweight plastic versions of sorne sys-
replaces anaesthetic and 0 2 taken up by the patient; tems are ideal for animais with infectious diseases. The
flow requirements are based on the animal's 0 2 con- ease of sterilization depends on the system 's complex-
sumption. In non-rebreathing systems, fresh gas is ity: circle systems are diffic u lt to steri !ize. Sterilization
needed to elute co2from the system; flow require- procedures are beyond the scope of this article.
ments are based on multiples of minute ventilatory
volume (Vm). As these are considerably greater than
0 2 consumption (Figure 4.4), non-rebreathing systems
are uneconomical in large animais, during prolonged
procedures or wh en carrier gas and va pour economy is
important, e.g. anaesthesia with isoflurane.
To-and-fro

~
Inclusion of N20
The use of N20 in rebreathing systems is potentially
hazardous when using ' low-flow' or closed systems.
J ackson-Rccs Lack
Uptake of 0 2 and N20 from the system occurs at C ir cle mod ificd Ayre's T-piccc
different rates and may leave hypoxic gas mi xtures.
This is identified by measuring inspired 0 2 concen-
trations. Dohoo et al. (1982) showed that flow rates Dead spacc
of 30 ml/kg/min 0 2 and 60 ml/kg/min NP allow
the safe use of N2 0 in rebreathing systems for dogs. Figure 4.5: Mechanical dead space.
These high flow rates limit partial rebreathing Reproduced from ln Practicc (1995) 17, pp. 229- 237. witlt permission.
Anaesthetic Equipment 27

Advantages leaking through the parti y opened pressure-relief valve.


Low gas flow requirements This is the easiest system to operate and therefore the
Low volatile agent consumption rate most common. Figure 4.7 shows the advantages and
'Closed' or 'low flow ' options disadvantages of closed and low flow systems.
Expired moisture and heat conserved Nitrous oxide cannot be safely used in rebreathing
Ventilation altered (spontaneous to controlled) systems unless inspired 0 2 or patient arterial 0 2 ten-
sions are monitored or high flows are used.
without changing system performance or
efficiency
Denitrogenation
Low explosion risk (when explosive gases are used)
At the onset of anaesthesia, patients expire consid-
Less pollution than other anaesthetic systems
erable volumes of nitrogen, which may lower circuit
Disadvantages 0 2 to hypoxic levels unless purged through the
High resistance to breathing pressure-relief valve ( denitrogenation). Hypoxic gas
Nitrous oxide cannot be safely used in mixtures are likely when N 20 and/or closed systems
rebreathing systems at low flows are used. Denitrogenation is achieved using high
Expensive to purchase f low rates fo r the first 10- 15 minutes of anaesthesia.
Regular replacement of soda lime required Alternatively, the reservoir bag s hould be emptied
Denitrogenation required every 3 minutes for the first 15 minutes and every 30
Inspired gas content undetermined minutes thereafter.
Slow to change leve! of anaesthesia
Cumbersome Anaesthetic concentration
Cannot be used with trichlorethylene* The rate of change of gas concentration in rebreathing
Figure 4.6: Advantages and disadvantages ofrebreathing systems is inversely proportional to the volume of the
systems. *No longer available as an anaesthetic. system and directly related to the rate of gas inflow.
Sevoflurane, a volatile agent currently undergoing Usually, circle systems have greater volumes than to-
clinicat evaluation in animais, is unstable in, and and-fro circuits, so rapid increases in concentration
absorbed by, soda lime.
(required, for example, when animais become lightly
anaesthetized) rely on greater inflow rates and vapor-
Valve position izer settings. Flowmeter and vaporizer perfonnance
Repeated operation of pressure-relief valves located must meet this requirement.
by the head, e.g. to control ventilation, dis ru pts surgery
and may compromise sterility. Coaxial systems reduce
this problem. Advantages
Optimum fresh gas economy
Ease of scavenging Low pollution and explosion risk
A scavenging hose attached at pressure-relief valves Maximum preservation of heat and moisture
close to the patient contributes to drag. Minimum waste of inhaled anaesthetic
Self-regulating anaesthesia in spontaneously
breathing subjects when vaporizers are
REBREATHING SYSTEMS incorporated in the breathing system (VIC)

In circle and to-and-fro systems, soda lime, or Disadvan,tages


bara-lime in the USA, removes C0 2 from expired Constant attention to system required
gas. Advantages and disadvantages of rebreathing Accurate flowmeters 0-1000 ml/min required
systems are shown in Figure 4.6. Sorne features of Denitrogenation mandatory
rebreathing system operation described in the figure Nitrous oxide inclusion is imprudent unless
require explanation: oximetry performed
Slow response to changing inspired oxygen
Closed and low flow systems concentration
Rebreathing systems are used in one of two ways. In Use possible only in subjects with oxygen
closed systems, gas inflow precisely replaces anaes- consumption lying in a range of vaporizer
thetic and 0 2 ta ken up by the patient (approximately 5- function
10 ml/kg/minis required). Under these conditions the High output vaporizers required (VOC) or high
pressure-relief valve is shut and the system described output low resistance vaporizers (VIC)
as closed. Oxygen consumption depends on factors Risk of overdose during intermittent positive-
related to metabolic rate, but typical values are given in pressure ventilation when VIC
Figure 4.4. In low flow systems, 0 2 delivery exceeds Figure 4. 7: Advantages and disadvantages of closed versus
basal requirements (> 10 ml/kg/min), with surplus gas 'lowflow' systems.
28 Manual of Small Animal Anaesthesia and Analgesia

~
3
Patient

' - - - - - - 1 ~Fresh
gas

Figure 4.8: Circle anaesthetic breathing system.


Repr01/uudjrom ln Practicc ( 1995) 17, pp. 229-237. willt ptrmissiotJ.

Circle system was sited at the 'Y' connector, which made operation
Circlesystems (Figure 4.8) have valves th at permit the difficult. Pressure-relief valves should be shrouded for
movement of gas in one direction. There are seven attachment to scavenging hoses.
circuit components: fresh gas inflow (1), inspiratory
and expiratory unidirectional valves (2 and 4), the Reservoir (rebreathing) bag
patient 'Y' connector (3), a pressure-relief valve (5), a This is normally sited between the expiratory valve
reservoir bag (6) and an absorbent canister (7). Sorne and absorber; it allows IPPV and assists in the moni-
circuits have manometers that are useful but not vital. toring of respiratory rate and tidal volume (Vt). The
The relative positioning of the components influences bag's volume should be 3-6 times that of the animal's
efficiency mainly when circle systems are used in a Vt. Oversized bags increase circuit volume, diminish
low flow manner. perceptibi lity of respiration and are harder to
compress manually. Inadequately sized bags collapse
Fresh gas inflow during large breaths and over distend during expira-
This pipe connects the circuit with the common gas tion. Forsmall animal use, 2,4 and 6litrecapacity bags
outlet on the anaesthetic machine. Its location np- are required.
stream of the inspiratory valve and downstream from
the canister allows best control of inspired gas compo- Absorbent canister
sition. Siting the canister on the expiratory limb downstream
from the pressure-relief valve allows co2to be ex-
Unidirectional valves pelled before it reacts with, and consumes, soda lime.
These are light transparent dises that rest on the edge of In thls position, dust aspiration from the absorber
annular valve seats, enclosed within a gas-tight trans- granules is unlikely, although heat conservation in the
parent dome. Painted indicators on the dises accentu- breathing system is poorer.
ate their movement. Units are easily disassembled for The filled canister contains approximately 50%
cleaning and drying. absorbent granules and 50% air space. Efficient ab-
sorption requires the air space volume between the
'Y' connector granules to be greater than the Vt and so the minimum
This connects inspiratory and expiratory limbs with working soda lime volume required is 2 x Vt. Greater
ETT connectors or masks. In paediatric systems it has volumes than this are needed because the absorbent is
a septum that di vides inspira tory and expiratory flows, progressively inactivated during use. Large canisters
reducing mechanical dead space. may confer increased resistance to breathing, but re-
qui re Jess frequent changing.
Pressure-relief valve For optimum absorption efficiency, the canister
This is an adjustable unidirectional valve venting at width: height ratio should be 1: 1 or greater. Gas flows
pressures from 1-50 mmHg. It is opened to release more slowly through large-diameter canisters, and
surplus gas from low flow systems and during resistance caused by turbulent flow is reduced.
denitrogenation. It is closed when bag compression is Canisters for circle systems should have two com-
imposed for lung inflation. ln old systems the valve partments. When absorbent in one compartment be-
Anaesthetic Equipment 29

cornes exhausted, it should be discarded. After refill- veolar ventilation increases, which augments vapor-
ing, the canister should be replaced in the reverse izer output and so anaesthesia deepens. Relatively
direction. Ex pi red gas then passes through the remain- inexpensive lightweight plastic systems are now avait-
ing partially used absorbent, exhausting this com- able. One range is disposable.
pletely before reaching the newly filled compartment.
Circ le system canisters may have a switch that allows Disadvantages
gases to bypass the absorbent. This is used after con- Circle systems are complex, cumbersome and difficult
trolled ventilation when low arterial co2 tensions may to sterilize. Circuits described as paediatric and adult
prevent resumption of spontaneous breathing. Switch- human (small animal) differ in hose length and radius
ing the absorbent off allows circuit co2levels to rise and in the volume of absorbent canisters. Despite avail-
without curtailing 0 2 and anaesthetic delivery. Inad- ability, circle systems for small dogs and cats are less
vertent operation of circle systems with absorbent popular in the UK than elsewhere because of resistance
switched off (excluded) may result in fatal hypercap- caused by absorbent and valves, and because dead space
nia. Absorbent canisters should be easy to open, fill, in the 'Y' connector is alleged to be excessive. Circle
reseal and replace. They should a Iso have a window so systems designed for human use should not be used in
that the colour of the absorbent and the extent of its dogs weighing less than 15 kg, although they are useful
filling can be checked. and efficient in larger dogs. When circle systems are run
Canisters for hu man use aresuitable fordogs weigh- with VIC, overdosage risk increases when ventilation is
ing over 15 kg. Mechanical dead space does not in- controlled. When this is required, animais must be
crease in the course of ti me but absorbent exhaustion closely monitored and vaporizer output curtailed.
occurs more acutely than with to-and-fro systems, and
replacement may become necessary at inconvenient To-and-fro (Water's) system
times during surgery. Small animal systems require In this system, gas oscillates through absorbent gran-
about 1.5\itrecanistersaccepting 1.35 kg of absorbent. ules in the Water's canister, which in companion
animais is used in a horizontal position (Figure 4.9).
Roses To-and-fro and circle systems are compared in Figure
Corrugated hosing prevents kinking but generates tur- 4.1O. Desirable features of to-and-fro circuits include:
bulent gas flow and therefore increases resistance.
Smooth-walled hose with externat ribbing is prefer- Fresh gas inflow
able. Hoses for human use (22 mm diameter) are Situating gas inflow next to the ETT connector reduces
suitable for companion animais. mechanical dead space and allows optimal control
over anaesthesia; dia lied concentrations of anaesthetic
Advantages are preferentially inspired.
Circle systems are very efficient and most suited to
dogs weighing over 15 kg. They are more convenient Fil ter
to use than to-and-fro systems. Efficiency becomes A metal gauze screen sited at the patient end of the
particularly high when circle systems are used in a canister lirnits inhalation of alkali dust produced by
closed fashion (see Figure 4.7). The Komesaroff and agitation or inferior-grade absorbent.
Stephens' anaesthetic machines are designed for closed
use and have been employed in dogs as small as 2 kg. Scavenging shroud
The leve! of anaesthesia in animais connected to sys- Old to-and-fro systems may not have a scavenging
tems with VIC is to sorne extent self-regulating; as shroud fixed to the pressure-relief valve; this makes
animais become more lightly anaesthetized their al- effective scavenging difficult.

Scavenge
....._
Patient 11111111111

11111111111 Fresh gas


Figure 4.9: Horizontal to-and-fro breathing system.
Reproducedfrom ln Prn clicc ( 1995 ) 17, pp. 229- 237, ~\·irh permission.
30 Manual of Small Animal Anaesthesia and Analgesia

Circle
Advantages
Simplicity and durability make to-and-fro systems
Advantages ideal in animais with infectious airway disease, as they
High gas efficiency are readily sterilized.
Mechanical dead space remains unchanged with
use Disadvantages
Bronchiolitis unlikely Considerable circuit drag rend ers the system cumber-
Low circuit inertia some; extubation is possible when inadequate )y anaes-
Ventilation readily controlled theti zed animais move (altho ug h a Iightwe ight plasti c
system is now ava ilable). The proximity of the pres-
Disadvantages
sure-relief valve is awkward when IPPV is requ ired
Expensive
du ring head, neck or denta l surgery. Mechanica l dead
Complex, cumbersome and difficult to sterilize
s pace increases with time. Chemical bronchiolitis
To-and-fro and hyperthermia are weil known problems. Chan-
nelling occurs in the horizontal to-and-fro system.
Advantages
High gas efficiency
Bidirectional gas flow irnproves carbon dioxide
scrubbing efficiency NON-REBREATHING SYSTEMS
Greater heat conservation (hyperthermia is
Non-rebreath ing (sometimes known as 'semi-closed'
possible in high ambient temperatures)
in the UK) systems do not use C02 absorption and re ly
Lower resistance to breathing than with circle
on hig h gas flow rates (based on multiples of minute
systems (no valves and lower overall circuit
volume (Vm)) to flush expired C02 from the circuit so
length)
that it cannot be rebreathed at the next breath. Advan-
Low circuit volume: denitrogenation achieved
tages and disadvantages of non-rebreathing systems
rapidly; rapid changes in gas concentration
are listed in Fig ure 4.1 1.
Simple, robust construction
Portable; easily moved from room to room, and in
field
The Magill system
The Magill system consists of a reservoir bag (volume
Easily sterilized
Inexpensive
3-6 x Vt) and a corrugated hose that ends at an
ex piratory (He idbrink) valve (Figure 4.12). The
Disadvantages expiratory bose volume must exceed the Vt of the
Valve position is inconvenient for positive- animal otherwise rebreathing occurs.
pressure ventilation
Mechanical dead space increases during surgery
as absorbent is exhausted
Advantages
'Channelling' of gas over absorbent occurs in
poorly packed horizontal Water's canisters Low resistance; ideal for small animais and birds
Bronchiolitis; aspiration of al kali dust from Simple construction
canister may cause chemicallung injury Inexpensive
Considerable drag: system has much inertia and is Soda lime not required
inconvenient during head surgery Ins pired gas content sirnilar to that ' dia lied' at
anaesthetic machine
Figure 4.10: Comparison of circle and to-and-fro systems.
Denitrogenation not required
Canister Rapid change in levet of anaesthesia
Dimension requirements are the same as those for Can be used with trichlorethylene and sevoflurane
circle systems. Modern horizonta l canisters are made Disadvanta ges
from transparent perspex, allowing the colour of the
soda lime and filling adequacy to be checked. The High gas flow requirements
latter is important; in horizontal canisters that are High volatile agent consumption rate
improperly fi lled, expired gas ' chatmels', i.e. it takes Hig h running costs
the low resistance path over the absorbent granules so Expired moisture and heat usually lost
that C02 is not absorbed. Fordogs weighing over 10 kg Ventilatory modes affect system performance
it issaid that canisters designed for hu mans, containing Different types of non-rebreathing circuits behave
0.5 kg absorbent (650 ml volume), are satisfactory. differently and have different flow
requirements
Rebreathing bag Figure 4.11: Advantages and disadvamages ofnon-
See reservoir bags above. rebreathing systems.
Anaesthetic Equipment 31

Fresh gas

Patient

Figure 4.12: Mag ill breathing system.


Reproducedf rom ln Practicc ( 1995) 17, pp. 229- 237. tl"ith permissior1.

Gas flow (Figure 4.13) a reservoir bag connects to an outer


Rebreathing is prevented when gas flow rate equals inspiratory limb; this surrounds an inner expiratory
or exceeds patient Vm (see Figure 4.4) . When N2 0 is tube that ends at the expiratory valve, which is posi-
used, its flow rate is included within this value. For tioned at the machine connecter.
example, to supply 66% NP to a dog of 15 kg body
weight (with a Vm of 3 litres), flow rates of li/min 0 2 Gas flow
and 2 1/min N2 0 are required. Similarly, 1.5 1/m.i n Despite theoretical considerations, the behaviour of
each of 0 2 and N2 0 wou Id provide the sa me dog with the Lack and Magill systems are different; the Lack
a 50 % mixture. · system was found to be slightly more efficient than the
Magill system in dogs (Waterman, 1986). A fresh gas
Advantages flow rate of 120 mlfkg/min prevented rebreathing in
The Magill system is an efficient general purpose dogs connected to a Lack system, but rebreathing
circuit for most companion animal cases up to perhaps occurred when the same animais were placed on a
60 kg bodyweight. Gas flow rates required fo r these Magill circuit. There is an inverse relation between
and larger animais may exceed flowmeter capability, bodyweight and the fresh gas flow rate required to
and reduce economy. The circuit is readily maintained prevent rebreathing. Gas flow rates of 193 ml/kg/min
and sterilized. were safe for most dogs weighing between 10 kg and
15 kg, and 122 mlfkg/min fo r dogs over 15 kg. Expira-
Disadvantages tory resistance in the Lack system is also lower than
Mechanical dead space, inertia and considerable that of the Magill system, and so the former may be
expiratory resistance preclude the usefulness of the safer in small animais.
Magill system in cats and in dogs with bodyweights
<5 kg. The location of the Heidbrink valve is incon- Advantages
venient for scavenging and operation, especially The circuit is lightweight and exerts Jess drag than the
during surgery on the head. The system should not Magill system. Valve position facilitates operation and
be used for prolonged positive-pressure ventilation scavenging. The system is 1.5 m long, allowing posi-
because alveolar gas is rebreathed, causing hyper- tioning of the anaesthetic machine away from surgery.
capnia. Higher gas flow rates and an altered ventila- Lack systems can be used in place of the Magill
tory pattern permit IPPV without rebreathing, but system; they are more efficient. The expiratory resist-
this cannot be recommended when alternative sys- ance in the Lack system is considerably lower than that
tems are readily available. in the Magill (and the Bain (Mapleson D)) circuit
(Humphrey, 1983). In largê dogs, gas flow rates of200
The Lack system ml/kg/min in the Ma gill system and 120 ml/kg/min for
This coaxial system was originally designed for use in the Lack system prevent rebreathing. The advantages
humans in an attempt to overcome the inconvenient of coaxial systems over non-coaxial systems are listed
valve location in Magill circuits. In the Lack system in Figure 4.14.
32 Manual of Small Animal Anaesthesia and Analgesia

Figure 4.13: Lack breathing system.


Repr()(/ucedfrom ln Practice ( / 995) 17, pp. 229- 237, with permission.

Simple design
Ayre's T -piece
Lightweight plastic construction and absence of Gas t1ow
valves at the patient end minirnizes drag Four T -piece configurations are possible, based
Valve and reservoir bag position at the machine on the volume of the expiratory limb. In the most
end aUows easy adjustment, imposition of effective type, expiratory limb volume exceeds the
patient's Vt and has no reservoir bag nor expiratory
controlled and assisted ventilation and scavenging
valves (Figure 4.16A).
System length allows intermittent positive- Gas flow rates for T-piece systems must exceed
pressure ventilation to be performed sorne double the Vm otherwise expired gas is rebreathed
distance from the animal (2 x Vm). Rapid respira tory rates with short expira tory
Small volume reservoir bag on sorne versions of pauses may require even higher (3 x Vm) flow rates.
the Bain system allows easy recognition of Advantages
breathing movements Minimal mechanical dead space and resistance make
Simple construction favours cleaning and the T -piece ideal fo r cats, small dogs (bodyweight < 5
sterilization kg), neonates and birds. It is simple, inexpensive and
easy to sterilize. Modest drag occurs because two
In the Bain system, inspired gases (inner limb) hoses are present. The system is scavenged with appro-
are said to be warmed by expired gases in the pria te connectors.
outer expiratory tube
Disadvantages
Figure 4.14: Advantages of coaxial breatl!ing systems.
Ventilation is controlled by occluding the distal end of
the expiratory limb, but gas flow must be increased
Disadvantages otherwise the duration of inspiration is prolonged and
Older versions had high expiratory resistance and limits adequate ventilation.
the inner hose could become broken or disconnected,
causing considerable rebreathing. T he system is stiff
and inconvenient to use in very small animais. Venti-
lation should not be controlled with this system.

The parallel Lack system


Problems of coaxial geometry (disconnection, fracture
-
l'a tient

or kinking of the itmer limb) are avoided when the


inspiratory and expira tory Limbs are juxtaposed (Figure
4.15) as in the para liel Lack system. The system behaves
Like a Magill attaclunent, although the additional bulk
created by two hoses increases drag, so conferring little Figure 4.15: Parallel Lack breathing system.
advantage in anaesthesia of very small animais. Repro<iuct•dfrom ln Praclicc ( 1995) 17, pp. 229- 23 7. with permissiot~.
Anaesthetic Equipment 33

Patient
A

Patient

Scavenge

Fresh gas

Fresh gas
Figure 4.16: A y re 's T-piece and 8th Jackson-Rees modified A yre 's T-piece.
Reproducedfrom ln Prncticc ( 1995) 17, pp. 229- 237. wirh permission.

Ayre's T -Piece with Jackson-Rees' 1 kg is 10 ml, which makes the mechanical dead space
modification of both Bain and Lack systems unacceptably large.
This breathing system is an Ayre's T-piece with an
open-ended reservoir bag on the expiratory limb Gas flow rate
(Figure 4 .16B) . The system probably requires marginally higher
flow rates than corresponding T -piece systems, al-
Gas flow rate though reports on its performance vary. Man ley and
Flow rates of 2.5-3 x Vm are needed to prevent re- McDonell (1979a,b) recommended flow rates be-
breathing. tween 100 and 130 ml/kg/min in spontaneously
breathing dogs and concluded that gas flow rates of
Advantages 100 ml/kg/min are required when IPPV is imposed
The bag facilitates IPPV, and bag movement acts as a using a Vt of 20 mlf kg and respiration rates of 20 per
useful respira tory monitor. Ventilation is controlled by minute. In reviewing coaxial systems, Cul! en (1989)
occluding the bag's end, allowing distension, then recommends a minimum fresh gas flow rate of 200
squeezing the contents into the patient's lungs. The end ml/kg/min in spontaneously breathing dogs and
is then released. The system has the advantage of aT- increases this when respiration rate exceeds 15 per
piece, so is used in similar circumstances. Imposing minute. He suggests that high flow rates should
IPPV does not require increased flow rates. al ways be used in coaxial systems when the respira-
tory rate increases (Cullen, 1989).
Disadvantages
Scavenging the system may be complicated; connectors Advantages
tend to twist and cause rapid over distension of the bag. The (valveless) Mapleson Eor F versions are recom-
mended for cats and very small dogs because of low
The Bain system expiratory resistance. Ventilation is controlled by oc-
The Bain system is a coaxial T -piece with an inner cluding the expiratory limb in 'E' systems. In 'D '
inspiratory limb surrounded by an outer expiratory systems, the expiratory valve is closed then the bag
hose. The expiratory limb ends in: squeezed. In Mapleson F versions the reservoir bag is
used like that in a Jackson-Rees modification. The
A reservoir bag and expiratory valve, Mapleson circuit is useful for IPPV in small dogs and cats,
D (Figure 4.17A), or especially when access to the patient is limited. The
An open-ended tube, Mapleson E (Figure length of the system (1.8 rn) allows the anaesthetic
4.17B), or machine to be positioned away from the site of surgery,
An open-ended bag, Mapleson F (Figure 4.17C). improving access to the p{ltient. Spontaneous ventila-
tion is satisfactory in dogs weighing more than 10 kg.
Valveless Bain systems are preferred in spontaneously The system has low drag and mechanical dead space
breathing dogs, cats, birds and small mammals, while and is easily maintained and sterilized. It is claimed
the Mapleson D version can been used in large dogs. warm expired gas raises the temperature of gas flowing
Culien (1989) points out that the Vt of a kitten weighing in the inn er limb, conserving the patient' s temperature.
34 Manual of Small Animal Anaesthesia and Analgesia

.....,._ Patient
Fresh gas
Mapleson D

Patient
B

C Scavenge
~

Mapleson F
Fresh gas .....,._ QIT:::======:J
Figure 4.17: T/iree coaxial T-piece (Bai11) systems .
Reproducedfrom ln Pmcticc ( 1995) 17, pp. 229- 237. u'Îih permi..,s;on.

Disadvantages c ircui t has Jess dead space and is more efficient than
Expiratory resistance with high flo ws reduces the the Ba in system, but th at it is Jess versatile. The Bain
system 's usefulness in spontaneously breathing cats system ca n be used without a valve and in this
and sma ll dogs weighing less than 10 kg. Conversely, configuration has lower expiratory resistance.
tube diameters may impose too great a resistance for
gas movement in very large dogs breathing spontane- Disposable anaesthetic breathing systems
ously (Cullen, 1989) . A third complication occurs at A complete range of breathing systems is avai-lable
high flow rates when the ins piratory gas stream en- for single use in hu man patients . Constructed en ti rely
trains C0 2-rich gas from the expiratory reservoir, of plastic, these are lighter and Jess ex pensive, though
causing rebreathing. Another complication follows less robust, than traditional circui ts made of car-
disconnection, kin ki ng or twisting of the inner tube. bonized rubber and stainless steel. T hey can be
When this occurs the entire c ircuit volume becomes safely re-used in ani mais, but must be discarded
mechanical dead space, and severe hypercapnia en- when leaks develop (usually around the neck of the
sues. The outer limb is made of trans lucent plastic reservoir or re breathing bag) and after use on
and the inner limb is coloured (blue or green) so that anima is with infecti ve respiratory or systemic
abnormalities of the inspiratory limb are more obvi- disease. Disposable circle and to-and-fro systems
ous. Rebreathing problems caused by disconnection canna t be re-used once soda lime is expended,
of the inner limb prompted development of a para- although resourceful users have found ways to
lie ! Bain system. However, the integrity of the replenish exhausted absorbent.
ins piratory limb is easily tested by occluding its end
with a 5 ml syrin ge plunger; when gas is flowing, the Anaesthetic breathing system safety check
flo wmeter indicator fall s and/or the overpressure Before use, anaesthetic breathing systems must be
va lve is heard. examined and tested for leaks . Exarnination ensures
The re lative efficiency of coaxial systems has thatall components are present and in the appropriate
not been compared in animais. In man, the fresh gas position. Pressure-relief valves are checked for smooth
flow rate required to prevent rebreathing in the Bain operation, from f ully closed to fu lly open. In
system is three times grea ter than that needed in the rebreathing systems, soda lime is checked for fresh-
Lac k system. Cullen (1989) suggests that the Lac k ness. Testing for leaks is achieved by connecting the
Anaesthetic Equipment 35

breathing system to the common gas outlet, closing Advantages


ali valves (where present) and other ports where gas
may escape and connecting a manometer to the Accurate control of respira tory variables *
patient connector. The system is then filled with 0 2 Constant arterial gas tensions create stable plasma
to produce a pressure of 18-22 cmH 20 , which it pH and potassium levels
should hold for at !east 2 minutes. An occlusion test Regular rhythm depresses ventilation, provides
should be performed on the inner inspiratory limb of narcosis and improves operating conditions
the Bain system, wh ile the operation ofunidirectional Constant tidal volume (volume preset) aliows
valves should be checked in circle systems. compliance measurement
Mechanical ventilator frees anaesthetist for other
duties
Special ventilatory modes may be imposed
MECHANICAL VENTILATORS
Disadvantages
The lungs can be inflated by the application of
Unnoticed disconnectionfcuff deflation fatal in
pos itive pressure to the s ubject's airway (IPPV) or
' paralysed' casest
by periodically reducing the pressure around the
Mechanical failure possible
thoracic cage (negative-pressure ventilation) . N ega-
Lung trauma more likely if inappropriate
tive-pressure ventilation occurs in iron Jung type
variables are set
ventilators and has no application in veterinary an- Purchase and maintenance costs may be high
aesthesia. Positive pressure ventilation can be im- Some mechanical ventilators may be unsuitable
posed by manual or mechanical methods. The for ali patient sizes
advantages and disadvantages of the latter are listed Ventilators may become fomites i.e. harbour
in Figure 4.18. In veterinary practice, a ventilator transmissible respiratory pathogens
may be needed:
Figure 4.18: Advantages and disadvantages of mechanical
ventilation.
For short-term ventilation (1-4 hours) associated
*Examp/es indude tida l ra/ume, respira tory rate, peak impiratory press11re and 1:E ratios.
with general anaesthesia f PrtWIIIÎOII may be possible wiTh law press/m' ala n m;.

For long-term management of respiratory disease


or thoracic trauma
For short-duration intensive respiratory care (<24 Maximum inspiratory flow rates of 80 lfmin
hours). · aliowing:
Variable inspiratory times of 0.5-3.9 seconds
Requirements Frequencies of 5-50/min
A description of ali the ventilator types available for A Vt range of 50- 1500 ml
use in animais is beyond the scope of this chapter. A variable I:E ratio (1: 1-1:3.5)
Ultimately the choice depends on the machine being: The capability to control ali the above
simultaneously (altering one variable should not
Compact, portable, robust and easy to operate affect others)
Economical to purchase, use and maintain The ability to maintain output even when leaks
Electricaliy safe, isolated, suppressed and develop.
explosion proof
Capable of use with air, 0 2 mixtures and ali Venti lators should be capable of providing:
anaesthetics
Capable of allowing straightforward control and ' Sighs'
measurement of inspired 0 2 concentration (Fi0 2) Inflation hold (plateau)
Capable of humiclifying inspired gas Different airway pressure wave forms
Capable of nebulizing drugs Low expiratory resistance and positive-end
Capable of rapid disassembly for easy expiratory pressure.
steri 1ization
Capable of using disposable hoses They should be equipped with a pressure-relief valve,
Fitted with bacterial filters and deviees to do the following:
Capable of use with non-rebreathing or
rebreathing anaesthetic breathing systems Allow continuous monitoring of airway pressure
Capable of rapid conversion for paediatric use. (P) and of expired volume (V)
lndicate low pressure and/or circuit
Mechanical ventilators should have: disconnection and high pressure and/or pressure
overload
Adjustable flow rates lndicate low expired Vm and low Fi02
36 Manual of Small Animal Anaesthesia and Analgesia

Display flo w rate waveform (PV curve) Human ventilators


Indicate power fai lure Medical mechanical ventilators may be designed for
A llow rapid manual takeover. use in intensive care or in the operating room. These
categories are not rigid, as modern intensive care
In most types of ventilator, lung inflation is achieved deviees are also capable of delivering anaesthetic
either by the application of a pressure to the upper vapours. However, intensive care deviees tend to be
airway (pressure generation) or by the introduction of more complicated (and more expensive), being capa-
a preset volume of gas (flow generation). Constant- ble of a range of ventilatory modes and functions.
pressure deviees produce exponential changes in Ventilators used in anaesthesia are smaller, more re-
airway pressure and, within limits, compensate for bust, portable, easier to operate and Jess expensive than
leaks. The output of constant-pressure generators must those used in intensive care.
be periodically adjusted to compensate for changing
Jung compliance, which often falls during anaesthesia. Ventilators from human hospitals
In constant-flow generators, airway pressure and Jung Second-hand ventilators are available from human
volume increase in a linear fashion, because of constant hospitals or the health service and are usually good
flow. However, there is no compensation for leaks. value for money. They are sophisticated and likely to
With settings at minimum values, human deviees have the desirable safety features listed above. Com-
intended for adults are able to ventilate the lungs of ponents may, however, be difficult to obtain. Ma-
dogs weighing more than 20 kg. The lungs of small chines thataresecond-hand should becarefully checked
clogs and cats are more compliant than larger animais, and overhauled by trained technicians before pur-
and must be inflated at high respiratory rates and with chase.
Jow tidal volumes. Purpose-built paediatric ventila-
tors, or adult ventilators modified for children, may New medical ventilators
be suitable. Sorne modern aclult ventilators may be These are expensive complicated deviees and tend to
rapidly adjusted to control ventilation in human in- be difficult to operate because oftheir ability to repro-
fa nts; this normally involves the straightforward ex- duce complex breathing patterns. Most of these pat-
change of the cuvette and bellows, after a few screws terns are unnecessary in veterinary anaesthesia and so
have been slackened or removed . Simil arly, Man ley the purchase of such equipment is unwarranted.
ventilators can be rapidly adapted for use in small
subjects by inserting a low-flow restrictor that cur- Purpose-built laboratory animal ventilators
tails gas flow from the bellows more severely than Although most ventilators can be converted for use in
does the adult version. It should be noted that the children, care is still needed when they are used in
cuvettes and flow restrictors necessary for conver- puppies, small cats, birds and small mammals. Many
s ion are not integral parts of the ventilator; veterinary la boratory suppliers produce mechanical ventilators for
practitioners purchasing this equipment must ensure use in laboratory animais, e.g. rabbits and guinea pigs,
that the vendor supplies these separate components. which are suitable for use in small patients. They are
In very small dogs and cats, it may be necessary to relatively inexpensive, robust and simple to operate.
adapt paediatric ventila tors to prevent over expansion
of lungs. This can be accomplished by: Mechanical ventilators
The classification of medical ventilators is beyond the
Deliberately incorporating a ' leak' in the scope of this chapter. Ventilators commonly used in
inspiratory limb veterinary anaesthesia may be described either as 'bag
Creating a parallel resistance squeezers' or as 'minute volume' dividers.
Creating a parallel compliance, i.e. a distensible
bag. Bag squeezers or bag-in-bottle ventilators
These are the simplest form of ventilator, in which the
Alternatively, a laboratory animal ventilator may be bag, or bellows, is attached to the bag mount of a circle
used (see below). breathing system. The bellows are fi !led with a mixture
offresh anaesthetic gases and expired breath from the
Sources breathing system. The bellows are then compressed
either by electrically powered compressors or rotary
Purpose-built small animal ventilators blowers, or by exposure to high pressure delivered
Sorne purpose-built small animal anaesthetic ma- from a separa te 'driving gas' (02 or air) supply. When
chines incorpora te mechanical ventilators. These are the bellows are compressed, gas is expelled into the
not inexpensive and often Jack the warning and fail- breathing system and the lungs are thus inflated. Ex-
safe deviees required in medical anaesthesia. How- cessive gas flowing into the system is vented from the
ever, they are straightforward in operation and bellows through a pressure-relief valve that is open
generally robust. only between breaths. The bellows must be designed to
Anaesthetic Equipment 37

prevent inward gas leaks, i.e. driving gas must not ble of delivering intermittently very high flows. At
contamina te the delivered gas mixture. Most purpose- present, there are few published data to support the
built small animal ventilators (e.g. Drager SAV, clinical use of this ventilator.
Hallowell EMC2000 and Mallard 2400) are bellows
ventilators. Olderventilators (e.g. Metomatic SA) may Hoses
have suspended bellows that descend during expira- Up to 20% of the tidal volume set can be !ost by
tion. Such an arrangement does not allow easy detec- compression of gas within the ventilator and through
tion ofinadvertentdiscom1ection of the patient breathing expansion of corrugated hases, and so does not enter the
system because the bellows continue to go up and lungs. In non-breathing circuits this may contribute to an
down in phase with ventilator operation. Modern ven- increase in total dead space. Problems can be avoided by
tilators tend to be equipped with bellows th at ascend on using low-compliance hases and/or measuring deliv-
expiration; with this arrangement the bellows stop ered volume at the endotracheal tube connector.
moving as soon as inadvertent disconnection occurs.
Safety check
Minute volume dividers Before use, the ventilator and its contrais should be
These are driven by the gases that are ultimately checked for normal operation. The patient port should
delivered to the patient's lungs, i.e. the volume of gas be occluded to examine operation of the pressure-
supplied per minute to the deviee (in 1/min) is the relief valve. The disconnect alarm, if present, should
patient' s Vm. As Vm is the product of Vt and freq uency, be operational. Finally, an alternative means of Jung
only one variable can be altered once the flow rate is ventilation should be available in the event of ventila-
set; the other variable changes inversely. tor malfunction.
Three types of small inexpensive miniature Vm
dividers (which operate sirnilarly) have been evaluated
for use in dogs: the Minivent, Micravent and Automatic SCAVENGING SYSTEMS
Vent. These deviees are positioned at the patient end of
the corrugated tubing of the standard Ma gill attachment Contamination of the operating and recovery room air
after removal of the Heidbrink expiratory valve. Gas by waste anaesthetic ga ses and vapours can be limited
flowing into the breathing system causes the reservoir in severa! ways. Scavenging refers to the removal of
bag to distend and pressure within it to rise (for best expired waste gas from the expiratory valves, pres-
results the bag must be new and non-compliant, orstiff). sure-relief valves or expiratory limbs of breathing
Before inspiration begins, gas flow into the lungs is systems and ventilators to a site distant fro m the
prevented by a bi-stable valve that is held shut by a working environment. Gas scavenging systems are of
nearby magnet. As gas volume in the bag rises, a two types:
pressure is reached that overcomes the attractive force
between magnet and valve, causing the latter to snap Passive
open. Gas is discharged into the subject's lungs owing In passive systems, expired gases are moved by the
to elastic energy stored within the bag. As the lungs combined effects of gas flowing into the breathing
inflate, the pressure in the bag falls below that needed to system from the anaesthetic machine, expiratory ef-
keep the magnet and valve separate, so the latter closes. fort of the patient and elastic recoil in reservoir or
The deviees have one or two contrais that alter the rebreathing bags. Passive systems are simple but
pressure leve! at which the bag initiates inspiration. their function can be affected by prevailing winds at
The Manley Pulmovent is a more complicated the exit port. Furthermore, they must not involve
minute volume di vider. Incoming fresh gas enters a set excessively long scavenging bose, otherwise resist-
of bellows, which are restrained by springs. Pressure ance to expiration occurs . Passive systems either
within the bellows rises as they inflate. Once a pre-set empty to the atmosphere through ducts in walls, or
volume is reached, the cycling mechanis m trips a valve into a canister of activated charcoal attached to the
that allows the pressure in the bellows to inflate the anaesthetic machine. Activated charcoal does not
subject's lungs. However, not ali this pressure is ap- adsorb N2 0 and inefficiently deals with gas rich in
plied to the airway because a simple screw-in flow trichloroethylene. The !ife of a single canister is
restrictor is positioned proximal to the patient and, in inversely proportional to the concentration of gases
addition, there is a pressure-relief valve, which opens passing through it and ranges from 3-6 hours . The
at about 7 kPa. Thus a near constant pressure is exhaustion of an activated charcoal canister is indi-
generated, although it is app lied via a flow rate controL cated by increased weight.
The ADS 1000 is a minute volume divider mar-
keted in the USA for use in small animal patients. It is , Active
not designed for connection to an anaesthetic breath- In active systems, gas is moved by negative pressures
ing system. Presumably the source of the anaesthetic generated by an extractor fan or a hospital vacuum
gas mixture that supplies this ventilator must be capa- system from a shrouded expiratory valve to an air
38 Manual of Small Animal Anaesthesia and Analgesia

brake receiver (ABR) or scavenger interface. Exces- contains considerable volumes of gas. Pre-insertion
sive negative pressures may empty the reservoir bag inflation of the cuff will indicate the approximate
and make circuits of low flo w rate impracticable. volume of gas required to produce a good fit. How-
However, the ABR prevents the scavenger system ever, the best way of ensuring that cuff pressure is the
from exerting excessive negati ve pressure on the lowes t required for an airtight airway involves use of
breathing system and prevents build up of excess an in-circuit manometer. With the breathing system
pressure if the evacuation system fails (in which case closed, the reservoir bag is compressed until an in-
gases are vented to the atmosphere from the ABR). circuit pressure of 18- 22 cmH2 0 is achieved. The
The ABR also allows severa! systems to be scav- cuff is then inflated until 'hissing' ceases. If a ma-
enged without affecting the performance of the ex- nometer is unavailable, the lungs are held in a slightly
traction unit. The need for high fl ow scavenging is inflated state and the c uff similarly inflated. Anaes-
reduced by including a reservoir bag in the system. thetic gas mi xtures containing N 20 may cause cuffs
This accommodates expired gases and evens out that are inflated with air to expand. This can be
fluctuations during the respiratory cycle. avoided by inflating cuffs with gases from the anaes-
In the event that passive systems become occluded thetic machine. Alternatively, cuff pressures can be
or active systems fait, scavenging systems should monitored using a simple manometer attached to the
incorporate a pressure-relief valve that opens at low cuff- inflation pipe, and altered when necessary.
pressures, e.g. 5-10 cmHp.
Murphy pattern tubes
Theseare s imilarin most ways totheMagill pattern but
ENDOTRACHEALTUBES have a ' Murphy's eye', an oval ho le positioned on the
bevel facing the opening of the distal tube. This allows
Cuffed ETTs: gas flow to continue should the distal opening of the
tube become inadvertently positioned against the wall
Reduce the ris k of saliva, regurgitated stomach of the airway.
contents or irrigation fluids being inhaled
Allow effective imposition of IPPV Streamlined tubes
Reduce contamination from waste gas. The cuff-inflation pipe is embedded within the wall of
the ETT, which allows relatively large-cliameter tubes
Different patterns of ETTs have different advantages to be used in small airways. This configuration means
in differing circumstances. th at the tube cannat be eut short (to mjnjmize mechani-
cal dead space).
Magill pattern tubes
Both oral and nasal Magill pattern ETTs are available. Armoured, spiral-embedded or
Oral tubes are designed for orotracheal intubation and flexometallic tubes
have thicker walls than the nasal tubes. Oral tubes may These tubes are usua lly made of silicone rubber and
be either plain (uncuffed) or cuffed. The cuff is inflated have a steel wire or nylon coil embedded in the wall;
by means of an inflation pipe, which runs as an external the spiral resists kinking and collapse when extreme
moulding. When inflated properly, the cuff produces neck flexion is imposed, as in head or neck s urgery.
an airtight seal between the tracheal wall and the tube, Titis design has created uruque problems. Obstruction
which ensures inspired gases pass through the lumen and kin king is possible at either end of the tube where
of the tube. However, cuffs inflated to pressures ex- it is not reinforced by coils, and the flaccid bevel can
ceeding the perfusion pressure of the capillaries in the invaginate into the tube if pus hecl against the tracheal
tracheal mucosa (about 25-30 mmHg) cause pressure wall. Kinking may occur at the proximal (circuit) end
(ischaemic) necrosis of the trachea l mucosa and if the connector or catheter mount does not overlap the
subsequent tracheal cicatri zation. Overinflation can spiral. During boiling or autoclaving, repeated high
also cause respiratory obstruction when the wall of the temperatures soften nylon spirals; when the cuff is
tube is compressed into its lume n. The pipe inflated, the tube wall beneath the cuffbulges inward,
that inflates the cuff may be open ended or fitted caus ing obstruction. Furthermore, the steel wire
with a moulded stopper. The most useful pipe ends s pirals have resulted in the tube lumen remaining
in a valve, which accepts the male !uer nozzle of occluded after being crushed, precluding ventilation.
an inflating syringe and conveniently closes when F lexometallic tubes are considerably more expensive
the latter is removed. than the standard tubes.
On ali cuffed tubes, the turgidity of a pilot balloon The human trachea is relatively s mall, and so
connected to the cuff reflects the degree of cuff medical ETTs are only available in sizes up to 11 mm
inflation. However, this does not indicate an airtight internai diameter. Larger tubes, which are necessary in
seal, and balloons connected to low pressure-high medium and giant breeds of dogs, must be obtained
volume c uffs (see below) may fee! soft when the cuff from a manufacturer of veterinary equipment.
Anaesthetic Equipment 39

Mate rials held at the leve! of the incisors and is bent to follow
Endotracheal tubes are available in a variety of mate- the natural airway. The tip of a suitably sized
rials, which determines their properties, clinical use- tube ends at the spine of the scapula. If the tip
fulness and longevity. Red rubber tubes are relative! y extends beyond the 5th or 6th intercostal space, the
irritant, imperfect for prolonged intubation and firm; tube is too long and may enter a mainstem branchus
their curvature is predetermined. In contrast, plastic if the full length is advanced. Although sorne me-
(PVC) tubes are non-irritant, soften after a period in chanical dead space is weil tolerated by healthy
vivo and mould to body contours at 37°C. Disposa ble animais, excessive volumes may compromise those
plastic tubes designed for hu man use may be re-used in animais susceptible to hypoventilation and respira-
animais. The methodsofcleaningand sterili zationalso tory acidosis. In these, surplus tube should be re-
depend on the material of construction. Red rubber moved with scissors, or ventilation assisted using
tubes soften with time, frequent use and the necessary gas volumes equal to the normal Vt and additional
cleaning and sterilizing processes. Sorne materials mechanical dead space.
retain detergents and sterilants more tenaciously than Before use, ETTs must be rinsed of potentially
others and a more disciplined approach to their clean- irritant sterilizing solutions. The lumen should be
ing is required. For example, plastic products that have checked for patency (this is especially important in
undergone irradiation are said to react with ethylene small diameter tubes). The cuff should be inflated and
dioxide, to produce a ti ssue irritant, eth y lene left for 10 minutes before use to ensure its inflation is
chlorohydrin. symmetrical and sustained.

Cuff profile
The inflated cuffs of red rubber tubes adopta s pheri-
cal contour white those of plastic tubes adopt a LARYNGOSCOPES
rectangular outline. Because of this, the area of con-
tact between red rubber tube cuffs and the tracheal Laryngoscopes are used to hold the root of the tongue
mucosa is Jess than that achieved with plastic tubes. and thus improve tracheal examination of the glottis
Furthermore, a thin band of relative!y high pressure is and intubation. They are particularly useful in cats,
produced with spherical cuffs, which is more like ly to and in animais with either extensive pharyngeal soft
cause mucosal trauma. tissue, e.g. Staffordshire Bull Terriers, or small air-
ways, e.g. English Bulldog . They are useful when-
Low pressure-high volume cuffs ever pharyngea l or upper airway disease threatens
Low pressure-high volume cuffs with square cuff airway patency, and in Chow-Chows, whose darkl y
profiles have much reduced the incidence of iatro- pigmented mucous membranes complicate identifi-
genic tracheal stenosis in human patients. They can cation of the rima glottidis.
be difficult to introduce unless the cuffs are fully
evacuated by suction. Patterns
The laryngoscope consists of a handle, which con-
Problems with tube size tains the battery power source, and a blade, which
Using undersized tubes (in terms of diameter) is mounts the light. It should be noted that the hinge th at
an effective way to increase airway resistance and connects the blade to the handle is not of a standard
the work of breathing, accelerate alveolar collapse design, and some handles and blades are incompat-
and transudation and cause hypoventilation in spon- ible. One edge of the blade is bent at approximately
taneously breathing animais. In those breeds where 90 degrees to form the web, which itself curves 90
the use of undersized ETTs is unavoidable, e.g. degrees outwards or inwards to form the flange. The
English bulldogs, or in dogs with laryngeal or relative dimensions of these components vary and
pharyngeal masses, ventilatory assistance must be form the basis of a bewildering array of patterns. In
provided from the outset. the Macintosh pattern, the tongue, web and flange
The main problem in using tubes of inadequate form a reverse 'Z' white in the Miller pattern, they
length is tracheal extubation, which occurs with the forma reverse 'C'. An important feature of the bi ade
slightest head movement. Casual re-insertion of the is its straightness or degree of curvature. The Macin-
tube will, on most occasions, cause oesophageal tosh pattern features a curved blade white the M iller
intubation. Overly long ETTs create excessive and Wisconsin blades are straight; a curved design is
mechanica l dead s pace, which extends rostrally slightly more useful. Most laryngoscope patterns are
from the leve! of the inciser arcade to the point of available in adult and paediatric versions, and blades
the anaesthetic breathing system where inspiratory are available for right- and left-handed opera tors. An
and expiratory gas streams di vide. This is minimized 8 cm Macintosh blade is suitable for cats, and dogs
by choosing an appropriately sized tube: in the weighing less than 5 kg, white (adult) blade lengths of
conscious standing animal one end of the tube is 12 cm and 20 cm are suitable for most other dog
40 Manual of Small Animal Anaesthesia and Analgesia

breeds. The Michaels blade is a human paediatric Thus, cham ber inductions should be used only when
version that is well suited to cats. deemed necessary.
Before use, laryngoscopes must be clean and pro-
duce adequate illumination. The greatest risk to
patients, however, cornes from over-aggressive appli- SUCTION
cation and not from the laryngoscope itself.
The presence of a vacuum-generating (suction)
deviee on an anaesthetic machine facilitates the
MASKS removal of oropharyngeal or endobronchial secre-
tions . In large hospitals, the vacuum source is central,
The conical shape of the Halls mas k accommodates and a vacuum line installed as part of the piped air
many breeds of dog and is available in a range of sizes. supply; this is unfeasible in most veterinary practices.
However, these create excessive dead space for cats However, many ex-h ealth service anaesth etic
and brachycephalic breeds of dog and, because they machines possess an integral suction deviee, in
are made of black latex rubber, preclude examination which a variable vacuum is generated by the passage
of mucous membrane colour and the position of the of an adjustable jet of medical gas over a small
mouth and the nostrils. Commercially available cup- aperture. The vacuum thus created draws fluid along
shaped masks fitted with a rubber diaphragm circum- a suitable collection pipe into a reservoir. Despite
vent problems of inadequate visibility, but are made of their low cast, safety, simplicity and effectiveness,
hard plastic and, if used aggressively, can cause facial such deviees rapidly consume medical gas . Portable
injury. Furthermore, they add considerable mechani- suction deviees operating upon an electrically dri ven
cal dead space to the breatlùng system and so should reciprocating pump mechanism are available, but
only be used for induction, rather th an the maintenance are expensive to purchase, although cheap to run. It
of anaesthesia. must be possible to adj ust the vacuum generated
Before use, masks should be checked to ensure by ail suction deviees.
they fit firmi y with the chosen anaesthetic breathing
system. After use they should be washed in warm
soapy water and rinsed. Sterilization is necessary NEBULIZERS AND HUMIDIFIERS
after use in animais with infectious res piratory
diseases. The humidif ication of inspired gas preserves
mucoci liary function and limits evaporative heat
tosses from the respiratory tree, so is desirable in
CHAMBERS animais with tracheobronchial disease and/or those
predisposed to hypothermia. In any process of hu-
Commercially available clear perspex chambers midification, the size of the water droplets is most
are to be found in severa! sizes and are most usefu l important. Drop lets of 20 f.!ffi diameter tend to preci-
for inducing anaesthesia in animais intolerant of pitate out in cool parts of the deli very hases; those of
physical restraint. The chamber induction technique 5 f.!ffi pool in the trachea or upper respiratory tract
is satisfactory for fractious small dogs and cats, white those of 1 f.!m reach the alveoli. Deviees produc-
puppies and toy breeds, as weil as large birds and ing the latter may cause water over load, leading to
exotic species. Induction chambers should be large, water intoxication.
yet contain slots on the inner walls to accommodate
clear partitioning walls. The partitioning walls Heat- moisture exchangers
make it possible to create subcompartments that The simplest humidification technique involves
cater for patient size (the smaller the chamber, the artificial nases or heat-moisture exchangers. These
more rapid the rate of induction). The lid of the consist of an adapter attached between the anaes-
chamber should be capable of being fastened down thetic breathing system and the ETT connector.
rapidly, e.g. by toggle levers, and incorporate ports They contain a fine wire mesh on which expired
for fresh gas inflow, and an exhaust shroud that moisture condenses. This moisture then evaporates
connects to a scavenge duct. The edge of the lid and is re-inspired at the next breath. These deviees
should be recessed so that it fits snugly, and should be are s imple, but even those designed for use in chil-
lined with neoprene, or sorne other compressible dren tend to clog and may impose excessive resist-
material, to improve gas proofing. Suitably sized ance to spontaneous breathing in very small animais .
chambers can also serve as an 0 2 cage for the small They also contribute to mechanical dead space and
animal, and as an incubator and/or 0 2 cage for newly can act as effective fomites in animais with infec-
delivered whelps. When used for inducing anaesthe- tious respiratory disease. They operate best when the
s ia, removal of the patient after induction inevitably ambient temperature is law but require constant
causes release of anaesthetic vapour into the room. observation.
Anaesthetic Equipment 41

Humidifiers droplets, and are the most efficient deviees. Both


Humidification of inspired gas cana Iso be achieved by deviees can be used to create aerosols of water-soluble
bubbling dry gases through warm water. The effi- drug solutions.
ciency of this is increased by first passing the gas
through sintered glass, which increases the number
and reduces the size of gas bubbles formed. Moisture REFERENCESANDFURTHER
produced in this way, however, tends to condense out READING
in cooler parts of the delivery system.
Bain JA and Spocrcl WE (1972) A strcamlincd anaesthetic system.
Canadian Anaesthetists Society Journaii9, 426- 435
Nebulizers Cu lien LK ( 1989) Coaxial anaestheticcircuits in small animals.Journal
ofSma/1 Animal Practice 30,294-297
Nebulizers are another form of humidifier. In Dohoo SE, McDoncll WN and Dohoo TR ( 1982) A comparison offresh
gas-driven nebulizers, a flow of high pressure gas gas flows during anacsthesia with ni trous oxidc in the dog. Journal
of the American Animal Hospital Association 18, 900- 904
across an orifice causes water to be drawn up and Humphrey D ( 1983) A new anaesthetic breathing system combining
then broken into a spray of droplets in the high Mapleson A, D andE principles. Anaesthesia 38, 361-372
Man ley SV and McDoncll WN (1979a) A new circuit forsmall animal
pressure stream. In mechanically driven nebulizers, anesthesia: the Bain coaxial circuit. Journal of the American
water is dripped either on to a spinning dise (which A nimal Hospital Association 15, 61-65
Man ley SV and McDonell WN ( 1979b) C linicat evaluation of the Bain
splits the drop into many droplets before dispersal) breathingcircuit in sm ali animal anesthesia .Journal oftheAmerican
or on to a surface that is vibrated at 1-2 MHz fre- Animal Hospital Association 15, 67-72
Waterman AE ( 1986) Clinicat evaluation of the Lack coaxial breathing
quency by ultrasound. Ultrasonic nebulizers, although circuit in small animal anaesthesia. Journal of Small Animal
expensive, can be adjusted to alter the size of the Practice 27,591 -598
CHAPTER FIVE - - - - - - - - - - - - - - - - - - -

Patient Monitoring
Craig Johnson

INTRODUCTION appropriate to augment this basic monitoring with


mechanical aids, which give additional information
Ail patients should be monitored continuously during and allow a more precise picture of the patient' s status.
anaesthesia. The aim of monitoring is to gather infor- This in tum allows doser control over the course of the
mation about the physiological state of the patient so anaesthetic. The disadvantage of mechanical monitor-
that this can be used as an aid when making decisions ing deviees is that they in tum must be monitored to
about the management of the anaesthetic (Figure 5.1). ensure that the information they are giving is accu rate.
Appropriate monitoring should allow the anaesthetic Unexpected readings should be verified by examina-
technique to be tailored to meet the needs of the patient tian of the patient before they are acted upon.
and the surgeon, by detecting changes at the earliest
opportunity and thus allowing earl y intervention. Care-
ful monitoring should enable the detection of problems MONITORS
before they become severe, so that they can be treated
appropriately and crises can be avoided. Many aids to patient monitoring are available. These
Routine anaesthetic monitoring starts with watch- range from simple deviees, such as oesophageal
ing, listening to, and touching, the patient. This in- stethoscopes and heart rate meters, to more complex
eludes inspection of respiratory function and the colour and costly deviees such as cardiac output computers.
of mucous membranes, capillary refill time, listening The monitors included here have been chosen to give
to the sound of breathing and palpation of the periph- an overview of what is readily available, concentrating
eral pulse. Attention should be paid to the who le of the on equipment that is likely to be of use to the small
patient's environment. In certain instances it may be animal practitioner.

Variable (units) Dog Cat


Heart rate (beats per minute) 50-100 145-200
Respiratory rate (breaths per minute) 10-20 15-25
Temperature (0 C) 37.5-39.2 37.8-39.2
Arterial haemoglobin saturation (%) >95% >95%
pH 7.27-7.43 7.25-7.33
PaC02 (mmHg (kPa)) 28...:49 (3.7-6.4) 35-49 (4.6-6.4)
Pa02 (mmHg (kPa)) >100 (1.3) >100 (1.3)
Bicarbonate (mmolfl) 20-24 18-22
Base excess (mmolfl) -6-0.5 -6- -3
Arterial blood pressure (mmHg (kPa))
Systolic 120- 140 (15.8-18.4) ?? 120-140 (15.8- 18.4)
Diastolic 80-100 (10.5- 1.3) ??80-100 (10.5-1.3)
Mean 100- 110 (1.3- 14.5) ?? 100-110 (1.3-14.5)
Figure 5.1: Normal values for physiological variables in the dog and cat. There is some debate concerning these values.
44 Manual of Small Animal Anaesthesia and Analgesia

Oesophageal stethoscopes heat loss . This can distort the core area and give
The oesophageal stethoscope is an economical and misleading results if an adjacent site is used to monitor
useful aid to perioperative monitoring. It consists of a temperature. For example, rectal temperature usually
tube with a closed rounded end and a cuff just behind gives a good indication of core temperature, but du ring
the end, which is connected to the central lumen by a prolonged abdominal surgery, the rectum can be cooled
series of holes in the tube. The oesophageal stetho- by exposure to the environment and will no longer be
scope functions in the same way as a conventional a good indicator of core temperature.
stethoscope diaphragm and can be connected to a The most useful sites for measurement of core
stethoscope earpiece orto a dedicated amplifier with a temperature are the rectum and the nasopharynx. The
speaker or headphones. During anaesthesia, the latter is one of the closest sites to true core temperature
oesophageal stethoscope is lubricated and placed down in patients breathing through an endotracheal tube
the oesophagus to the leve! of the base of the heart. The (ETT). The temperature probe should be inserted into
depth to which it should be inserted can be estimated by the ventral nasal meatus to the leve! of the medial
measuring from the tip of the patient's nose to the canthus of the eye.
middle of the patient's chest via the caudal border of If core and surface temperatures are measured
the mandible and the manubrium. Once placed, the simultaneously an indication of peri.pheral perfusion
stethoscope's position should be adjusted until heart can be gained. This will not give absolute values, but
and breath sounds are loudest. can be used to follow trends in cardiovascu Jar function.
The oesophageal stethoscope allows the heart and An increase in the difference between core and surface
respiratory rates to be counted during anaesthesia temperature indicates that peripheral perfusion is de-
without the need to disturb even extensive draping of 'creasing and may be an early indication of reduced
the patient. In addition, the volume and character of the cardiac output.
sounds can give qualitative information about cardiac
and respiratory function. The information requires The electrocardiogram
interpretation in the same way as does conventional The electrocardiogram (BCG) gives an indication of
chest auscultation, and so the value of the information the electrical activity of the heart. It is recorded by a
provided by the oesophageal stethoscope increases as number of electrodes (usually three), which are at-
the operator becomes more skilled in its use. For this tached to the patient with clips, sticky patches or
reason it should be used on a regular basis on as many transcutaneous needles. Electrode gel or surgical spirit
cases as possible to develop a sense of normal variabil- is often applied to the electrodes to ensure good elec-
ity. This allows the detection of problems at an early trical contact. As with aU electrical monitors, the
stage. The oesophageal stethoscope does not give patient leads must be isolated from the mains supply.
direct information about tidai or stroke volumes and so This is usually achieved using optical isolators in the
its use should always be accompanied by other means preamplifier of the monitoring unit.
of assessment such as palpation of a peripheral pulse The electrodes are classically placed on three limbs
and observation of the reservoir bag. (both front limbs and the left hindlimb) to give a
standard lead configuration, but during anaesthesia
Deviees for measuring temperature this may not be possible owing to the position of the
A reduction in the patient's temperature can have patient or interference with the surgi cal field, and so a
profound physiological effects. Metabolism is a tem- base/apex configuration is often used. This places one
perature-dependent process and governs both the rate electrode dorsal to the heart (near the base) and one
of recovery from most of the drugs used during anaes- ventral to the heart (near the apex); the third electrode
thesia and a Iso the rate of oxygen (02) utilization that is placed at any distant point on the patient. This will
must be supported by the cardiorespiratory system. give an ECG that is suitable for diagnosing arrhythrnias,
Anaesthesia-induced hypothermia causes shivering in but it should be remembered that the detailed morphol-
the recovery period, which may substantially increase ogy of normal sinus rhythm may differ from that given
oxygen demand at a time when supply is reduced. in texts.
Traditional mercury thermometers are not suitable The ECG can give information about cardiac
for continuous use during anaesthesia, but there are a arrhythmias and about the myocardial environment. It
large variety of inexpensive deviees available that give should be remembered that the ECG gives no informa-
a constant reading. These usually have probes that are tion about the mechanical function of the heart and
suitable for rectal, oesophageal or nasal use, but can should not be relied upon as a sole monitor of cardio-
also be obtained with flat probes suited to measure- vascular function. Indeed in sorne circumstances a
ment of temperature at the extremities. heart can maintain a normal ECG for severa! minutes
The anaesthetist is usually concerned with the after the cessation of mechanical activity.
maintenance of core temperature. This can be meas- Cardiac arrhythrnias can only be accurately diag-
ured at a variety of sites, but consideration must be nosed and treated when an ECG is available (see
given to the surgical site where there will be increased Chapter 14). Changes in the shape of the ECG can also
Patient Monitoring 45

indicate alterations in the myocardial environment Usefulness


such as hypoxia, hypercapnia, hyperkalaemia, acido- The ECG is a useful monitor in that it provides
sis and hypercalcaernia. Many of these changes indi- information that cannot be gained in any other way.
cate that the overall condition of the patient is However it should not be relied upon as an indicator
deteriorating and, if diagnosed at an early stage, can be of cardiovascular function and should al ways be used
managed appropriately. in conjunction with other patient monitoring. The
ECG is most useful in situations where the develop-
Problems ment of cardiac arrhythmias or alterations in mye-
Most of the problems with ECGs relate to electrical cardial environment are likely to develop in the
interference or the failure of the monitor to detect a perioperative period. As the electrocardiograph is
signal due to poor electrical contact or the inadvertent easy to connect to a patient it can easily become part
dislodging of the leads. Artefactual waveforms ra rely of routine monitoring.
mimic the actual ECG and so are easy to spot. The type
of artefact can usually be diagnosed with sirnilar ease. The pulse oximeter
Common ECG artefacts are illustrated in Figure 5.2. The pulse oximeter consists of a probe connected to a
small computer. By shining light of two different
wavelengths (red and infrared) through a tissue and
5s measuring their relative transmissions, it is possible to
calculate the relative concentrations of oxygenated
and deoxygenated haemoglobin in the tissue. The
transmission of light changes with the cardiac cycle
and so by comparing the relative magnitude of the
change at the two wavelengths it is possible to measure
the 0 2 saturation of haemoglobin in the blood in the
arteries (responsible for this change). This value is
referred to as the· Sp02 and is usually quoted as a
1s
(b) percentage. Traditionally, the oxygen saturation of
blood measured using a hench oximeter is referred to
as the Sa02 ; Sp02 is used to indicate the method of
measurement used. In addition to providing a measure
of Sp02 , pulse oximeters display pulse rate and so are
a useful monitor ofboth cardiovascular and respira tory
(c) 0.5s function.
Pulseoximeters are very easy to use and can quickly
generate readings from most animais encountered in
practice. When there are problems, these are usually
due to the construction or placement of the probe rather
than the software, although it should be remembered
that many pulse oximeters were developed for use in
human patients and there may be problems from the
0.5 s large range of pulse rates encountered in veterinary
(d)
anaesthesia. There are nowa large variety of probes on
the market, many of which have been developed for
veterinary use (Figure 5.3). A machine with a variety
of probe types will be more flexible than a machine
with just one, but the potential usefulness of each of the
Figure 5.2: Examples ofvarious artefacts recorded during
perioperative electrocardiographie monitoring. (a) The probes available should be considered as sorne may be
ground electrode of the electrocardiogram (ECG) has prirnarily for human use. For example, finger probes
become dislodged. The baseline wanders upwards a cross the can be very difficult to use in small animais whereas
display area until the waveform moves out of range. ft is then probes designed for other areas, e.g. ear lobes, or for
recentred by the monitor but continues to move upwards.
(b) Slow movement of the baseline due to patient movement.
use in infants can be applied to veterinary patients
In this case the baseline continued to rise andfall with chest comparatively easily. Different operators get good
excursions during respiration. (c) Loss of signal due to lead results with different probes, and when considering the
disconnection. Here one of the leads was repositioned purchase of a pulse oximeter it is w·ise to try out severa!
resulting in a change in ECG shape. (d) Mains interference before deciding on a particular machine. Probes for
leading to the obliteration of the ECG by 50- 60Hz noise
oesophageal or rectal use operate on reflectance of
picked up from equipment close to the patient. ln this case
the interference was due to the animal being placed on an light, rather than transmission. They are convenient to
electric heating pad. position but are difficult to get consistent results from.
46 Manual of Small Animal Anaesthesia and Analgesia

other a rea of s kin is to be used, the signal can be great!y


improved by clipping the ha ir where the probe is to be
attached.

Ambient light: Pulse oximeters produce red and infra-


red light from light emitting diodes (LEDs). Bright
light falling o n the preplaced probe can overwhelm the
light from the LEDs and so prevent the lig ht sensor
from getting an accurate reading. This problem can be
easily solved by shading the probe with a drape or piece
of card.

Movement: Movement of the probe over the tissue


Figure 5.3: A selection ofpulse oximeter probes are
from which a signal is being measured will result in
available which are s uitablefor use at various sires. From artefactual changes in the transmission of light, which
left to right: surface probe; clip probe; oesophagea/frectal will obscure the signal. T his is a particular problem in
probe; tongue probe; clip probe. conscious animais or those recovering from anaesthe-
Photo courresy of17rames Medical. sia. If a pulse oximeter is to be used into the recovery
period, it is advisable to choose a site which is less
Problems likely to suffer from movement artefact and to secure
It is not uncommon for a pulse oximeter to fait to get \he probe firmly in position without undue pressure.
a reliable reading from sorne sites in sorne patients. For example, the tongue is often used for perioperative
With practice and careful probe placement it is pulseoximetry, but is less useful in the recovery period
possible to get good results from most veterinary as animais may lick or chew at it, stopping the probe
patients. The following can cause a pulse oximeter from recording a good signal and even damaging it. In
to fail to give a reading: these cases it is better to secure the probe to a digit with
a light bandage . This will allow the pulse oximeter to
Lack ofperfusion: The pulse oximeter takes its signal function well into the recovery period.
from the arterial blood as the blood perfuses the a rea of
the probe. If there is little or no perfusion then the Haemoglobin abnormalities: Pulse oximeters are
devi ce will beunable todetect a signaland will notgive unable to cope with abnorma l haemoglo bins such as
a reading. Lack of a signal can indicate that the probe methaemoglobin and carboxyhaemoglobin. The pres-
has been placed in an area that naturally receives little ence of these in the blood can lead to erroneous
blood, such as the tip of the piima, or that there is a readings. In patients where the presence of one ofthese
generalized lack of tissue perfusion. Particular care haemoglobins is suspected, pulse oximetry should not
should be taken with clip probes as the pressure of the be regarded as a relia ble indicator of Sp0 2 . The effects
probe can reduce perfusion to the underlying tissues of adrnixture of artificial blood substitutes on pulse
and can cause the probe to Jose its signal after a period oximetry have yet to be evaluated in animais.
oftime. This often occurs when the probe is located on
the tongue. To reduce this problem, the probe should Sites for·probe placement
be placed on a different part of the tongue every 10 to There are many possible locations for the pulse oxi-
15 minutes. meter probe. The best site in a given circumstance will
Inability to locate a signal due to poor perfusion is depend upon the type of probe, the size and type of
commonly encountered when anaesthetic teclmiques patient and the preferences of the clinician. Figure 5.4
including a:z-adrenoceptor agonists are used. These lists sorne possible sites.
drugs produce vasoconstriction mediated via receptors
in blood vessels and hypotension mediated via spinal Problems
receptors . The resultant reduction in cardiac output The pulse oximeter is non-invasive and so carries very
and consequent poor peripheral perfusion can prevent little risk of complications. The infra red light will heat
the detection of an adequate signal at the probe site. the tissues through which it shines, and very minor
Other causes of shutdown of peripheral perfusion, burns have been seen in sorne patients after prolonged
such as cold or the use of vasoconstrictors, may result probe use. These are usually seen as an area of redden-
in the Joss of signal from the pulse oximeter. ing where the probe was attached, which fades after the
probe is removed.
Pigment or fur: Probes often cannot get signais from
heavily pigmented or furred a reas . In most animais an Significance of information
area of unpigmented tongue or a white digit can be The pulse oximeter provides two impo rtant pieces of
found from which a signal can be obtained. If a digit or information- pulse rate and Sp02 at the probe s ite. The
Patient Monitoring 47

Site Type of probe Placement of probe


Ton gue Clip or tongue Place as far back on tongue as possible. Blood supply can
be occluded as tongue is pulled out of mouth. It sometimes
helps to replace tongue with attached probe into mouth
Symphysis of mandible Clip Useful in cats. Place probe between canines to shine
through tissues behind mandible
G.a stt·ocnemius tendon Clip Cats and small or thin dogs. Place probe over tissues
between tendon and tibia
Digit Clip Useful on white digits. Clip fur and place probe from side
to side across digit
Oesophagus Rectal Place as oesophageal stethoscope
Rectum Rectal Ensure that probe is adjacent to rectal wall and not
obscured by faeces
Superficial artery Flat Clip fur and place over metatarsal artery
Prepuce Clip Place across fold of skin between penis and body wall
Vulva Clip Place clip across one wall of the vulva
Scrotum Clip Place in area between testicle and body wall
Pin na Clip Useful in rabbits. Place probe across pinna from inside to
out as far down as possible
Figure 5.4: Sites for al/achment of pulse oximeter probes.

arterial blood at the probe site is almost always repr_e- rate shown by the ECG and the pulse oximeter may
sentative of the arterial blood as a who le because ofthe be due to differences in the rate-calculating algo-
mixing that occurs as the blood passes through the rithms used by the two deviees and are not necessarily
heart. Severa! important inferences can be drawn from a cause for concern.
this information. A change in pulse rate implies an alteration in
cardiovascularfunction, which is usually broughtabout
Perfusion: The presence of a signal indicates that the by changes in activity of the autonomie nervous sys-
tissues under the probe are being perfused by arterial tem. A rising pulse rate (tachycardia) is often an
blood. This implies that the heart is effectively pump- indication of inadequate anaesthesia or hypovolaemia,
ing blood around the body. Sorne pulse oximeters have and a falling pulse rate (bradycardia) is often an indi-
a waveform display or signal strength indicator, which cation of overdose of anaesthetic agents or of
can be used as a crude indication of increasing or overhydration . This information should be interpreted
decreasing perfusion. This indicator should be treated in the light of the clinical situation. Measurement of
with caution as the signal strength can be affected by central venous pressure (CVP) or arterial blood pres-
factors other than tissue perfusion. In addition, sorne sure can be helpful in differentiating between the
pulse oximeters automatically amplify the signal so causes of bradycardia and tachycardia.
that it isscaled to the size ofthe waveform display. This
renders the display useless as an indicator of perfusion. Saturation: The saturation of the arterial blood gives
Even when using units that do not scale the signal, a·n indication of the amount of oxygen carried in the
alterations in signal strength should only be used to blood as a percentage of the total carrying capacity of
alert the anaesthetist to possible alterations in perfusion. that blood. An alteration in packed cell volume (PCV)
They should not be re lied upon as the sole indicator of can cause a change in the total carrying capacity of the
peripheral perfusion. blood that will not be detected by the pulse oximeter.
The PCV should be borne in mind when interpreting
Pulse rate: The pulse rate indicated by the pulse arterial 0 2 saturation, e.g. there is less reserve 0 2
oximeter is an indication of the rate of effective carrying capacity in anaen'l,ic patients and a smaller fa li
stroke volumes and not of the rate of electrical activ- in saturation than would normally be of concern may
ity of the heart. This information can be used in result in inadequate delivery of 0 2 to tissues.
conjunction with an ECG to detect pulse deficits. lt Because 0 2 saturation is a linear measure of the
should be remembered that small differences in the carrying capacity of the blood (unlike partial pressure of
T
1
48 Manual of Small Anjmal Anaesthesia and Analgesia
1
~
~ 1 1
0 2 in arterial blood, Pa02), a given reduction of satura- ANALYSIS OF RESPIRATORY GASES
tion anywhere across the spectrum will reduce the 0 2
carried in the blood to the same extent. For example, The composition of the gas breathed in and out by an
assuming a haemoglobin concentration of 15 g/dl, a anaesthetized patient can provide valuable informa-
decrease in saturation of 5% will result in a reduction tion about the patient's cardiovascular and respiratory
in 0 2 content of about 0.85 mlfdl regardless of whether systems as weil as the extent of anaesthesia. Tradition-
the decrease was from 95-90% or from 85-80% . ally, physiological gases suchas 0 2 and carbon dioxide
Normal arterial blood saturation as measured by (C02 ) together with nitrous oxide (Np) and volatile
the pulse oximeter is considered to be between 95% anaesthetic agents have been measured by separate
and 100%. A reading of <90% is usually considered to monitors, although machines are now available that
indicate hypoxaemia. Cyanosis of the mucous mem- monitor ali of these gases. Severa! different methods
branes will not usually be noticed until arterial satura- are used to analyse respira tory gases and the following
tion reaches 70%. A normal reading implies that the are intended as examples. Measurement is made either
patient is breathing a sufficient volume of gas contain- on the gas stream as it flows into the ETT (main stream)
ing an adequate partial pressure of 0 2 , that the 0 2 is or by removing a continuous sample of gas for analysis
able to diffuse across the alveolar membrane and that inside the monitor (side stream).
the oxygenated blood is being pumped from the lungs
to the tissues. In the absence of a monitoring error, Measurement
falling saturation can indicate any of the following:
Carbon dioxide
A hypoxic gas mixture is being breathed Analysis of C02 is usually based on its ability to absorb
• There is insufficient minute volume (Vm) to infra red light. Peak absorption occurs at a wavelength
oxygenate the blood of 4.28 J..lffi, and at this wavelength there is little
There is an increased shunt fraction (proportion interference from other gases such as N 20. Continuous
of blood which passes through the lungs without monitoring of the co2 concentration in the gas pro-
becoming oxygenated) duces a readout which is usually displayed as a wave-
• There is an impairment of alveolar diffusion form (Figure 5.5). From the waveform, the end-tidal
There is insufficient cardiac output to deliver the and inspiratory co2tensions and the respiratory rate
blood to the tissues (usually accompanied by Joss can be measured, and these are usually displayed in
of signal). numerical fashion.

Because the supply of 0 2 to the peripheral blood Oxygen


can be interrupted at any stage in the process, it is wise Severa! oxygen measuring deviees make use of light
to investigate each possibility un til the cause is · absorption by this gas. Analysis of0 2 may also make use
isolated. of the paramagnetic property of this gas. Unlike most
A pulse oximeter reading of <90% represents an other gases (e.g. nitrogen), which are weakly repelled
immediate threat to the patient because it relates to the by magnetic fields, 0 2 is attracted by them. If a glass
blood that is currently perfusing the tissues. For this dumbbell containing nitrogen is suspended in a chamber
reason it should be investigated as a priority and by a filament and placed in a magnetic field it will rotate
appropriate action taken as soon as possible. on the filament. This arrangement will come to rest
when the tension in the filament equals the force devel-
Usefulness oped by the magnetic field on the gas in the two spheres
A pulse oximeter is a very useful deviee in routine of the dumbbell. When 0 2 is added to the gas in the
1
surgical patients. It c·a n be rapidly attached and is chamber it will be attracted to the magnetic field and
non-invasive, yet provides valuable information about tend to displace the spheres. This will alter the forces on
cardiovascular function and oxygenation of the a rte- the filament and the dumbbell will rotate to fmd a new
rial blood. It is especially useful in patients with equilibrium. A bearn of light is reflected from a mirror
respira tory insufficiency or where a procedure which placed on the dumbbell, and the position of the reflected
li is likely to compromise oxygenation, such as bron- bearn can be read off a scale that can be calibrated in per
choscopy or bronchoalveolar lavage, is to be carried cent 0 2 in the gas in the chamber. Over the respiratory
out. With an appropriate probe, a pulse oximeter is cycle the percentage of 0 2 can be measured, and inspired
also very useful during the recovery period where it and expired 0 2 displayed. The percentage of 0 2 ex-
can provide a relatively early indication of respira- tracted from the inspired gas is also often displayed.
tory depression or obstruction. It is useful in patients
receiving supplemental 0 2 therapy, and it can be used Nitrous oxide
to optimize 0 2 delivery and to help ensure that the The concentration of ni trous oxide is usually measured
blood remains weil oxygenated as the inspired 0 2 by absorption of infrared light in a similar mannerto that
concentration is reduced. of C02 • The wavelength of infrared light used is 3.9 J..lm.
Patient Monitoring 49

(a)
the respiratory cycle. Which of these values is from
1s inspired gas and which is from end-tidal gas will vary
%] with the course of the anaesthetic. When the patient is
ta king up anaesthetic agent at the start of anaesthesia,
the greatest value will be from inspired gas, but at
the end of anaesthesia when the agent has been
(b) 1s removed from the inspired gas the greatest value will
7.5 be from expired gas. The monitor will be unable to
differentiate the two unless it also measures another
gas such as C02 •
0
Significance of information
(c) 1s Carbon dioxide
Inspired COz is important as it is a sensitive indicator
of rebreathing and is used to ensure that the fresh gas
flow delivered to a non-breathing system is adequate.
:J It can also wam of a malfunction of the breathing
system such as the failure of a unidirectional flow
valve in a circle breathing system or soda-lime exhaus-
(d)
tion. It should, however, be noted that sorne breathing
lOs systems such as the Bain and Ayre' s T-piece can allow
a small amount of rebreathing under normal operating
circumstances. The absence of C02 in the expired air
may indicate that the anaesthetic system is discon-
nected from the ETT, that the tube is incorrectly placed
(usually in the oesophagus) or that there is no effective
Figure 5.5: Examples of end-tidal carbon dioxide (ETC02) gas exchange taking place in the lungs.
traces recorded during the perioperative period. (a) Normal
waveform showing return to 0 with each inspiration and
The gas contained in the upper airway at the end of
plateau as alveolar gas is expired. The peak of each cycle is expiration was in the alveoli at the start of expiration.
taken as end-tidal co2(marked by arrow). (b) ln this Because alveolar gas is equilibrated with arterial blood,
recording fluctuations can be seen in the waveform du ring end-tidal gas concentrations reflect arterial gas con-
the expiratory pause. These are in lime with the heart beat centrations. End-tidal C02 concentration is closely
and are due to gas moving in and out of the chest as the heart
contracts and relaxes. (c) Abnormal waveform showing
related to arterial COz tension unless there is respira-
hypoventilation. The tidal volume is reduced and no alveolar tory dysfunction such as the presence of excessive
plateau is reached at the end of expiration. ft would be shunt or dead space. End-tidal C02 concentration is
expected that true end-tidal co2would be higher than the related to the balance between COz production (meta-
peak of this recording. (d) Sudden decrease in end-tidal C02 bolic rate) and COz removal (alveolar Vm). Changes
due to reduction of cardiac output. This recording was taken
under anaesthesia usually relate to Vm and give a
during ligation ofa patent ductus arteriosus. The reduction
in cardiac output was due to tamponade caused by bleeding good indication of hypoventilation or hyperventila-
into the pericardial sac from a torn pulmonary artery. tion. This information can be useful in helping to
assess adequacy of anaesthesia. A sudden fall in end-
tidal COz concentration can indicate a sudden distur-
Volatile anaesthetic agents bance in pulmonary perfusion such as cardiac arrest or
Traditional anaesthetic agent monitors have also uti- pulmonary embolism. Complete loss of the end-tidal
lized the absorption princip le of infra red light, but this C0 2 waveform can indicate apnoea or the disconnec-
has been associated with problems such as interference tion of the patient from the breathing system. More
from changing N2 0 concentrations in the gas. A par- subtle alterations in respiratory function can be de-
ticular problem in veterinary anaesthesia has been tected as alterations in the shape of the waveform (see
interference from methane, which occurs in the ex- Figure 5.5). With non-rebreathing circuits, the con-
pired gas of herbivores su ch as horses and ruminants. stant flow of fresh gas close to the endotracheal tube
A newer technique that is not affected by other gases causes mixing of expired gas and fresh gas, making
passes a stream of gas over a piezo-electric crystal. end-tidal observations un;eliable with this type of
When a voltage is applied to the crystal, the crystal breathing system.
oscillates and the frequency of this oscillation is al- The respiratory rate of the patient is usually de-
tered by the concentration of volatile agent in the gas rived from the C02 waveform and can be combined
stream. Anaesthetic agent monitors usually display the with the concentration of end-tidal COz to give an
minimum and maximum agent concentration through indication of the patient's respira tory function. Rapid
50 Manual of Small Animal Anaesthesia and Analgesia

respiratory rates can be associated with an increased Volatile anaesthetic agents


Vm due to surgical stimulation. In this case the The inspired and expired concentration of volatile
concentration of end-tidal C0 2 will be low and the anaesthetic agent is largely used as a teaching and
shape of the waveform will be normal. Anaesthetic research tool. The concentration of end-tidal anaes-
agent overdose can also lead to a rapid respiratory thetic agent is related to the effect of the agent at a
rate, but in this case it is accompanied by a reduced steady state and is used in the definition of minimum
tidal vo lume (Vt), and the resultant Vm will be de- alveolar concentration (MAC). When used in the clini-
creased with an increase in end-tidal C02 concentra- cat setting it is unwise to rely on an agent monitor to
tion. Under these circumstances the appare nt judge adequacy of anaesthesia as there is large vari-
concentration of end-tidal C0 2 dis played by the moni- ability between patients . Agent monitoring can be
tor can be low if Vt is ins ufficient to allow true useful to alert the anaesthetist to other problems espe-
alveolar gas to reach the gas sampling port during cially when using a rebreathing system. For example,
expiration. When this is the case the shape of the ifthe patient requires much Jess anaesthetic agent than
waveform will be abnormal with no true plateau. True expected, this may indicate the presence of another
decreased end-tidal co2concentration can be differ- problem such as hypothermia or a severe acid/base
entiated from this situation by squeezing the rebreathing disorder. Conversely, if much more agent is required
bag to produce a large Vt. If Vm is high, the concentra- than expected this may indicate that perioperative
tion of end-tidal co2 for this breath will be low, but if analgesia is inadequate.
there is respiratory depression the concentration for
this breath will be much hig her than for the patient's Usefulness
usual breaths and will bear a closer relation to PaC02 . Respiratory gas analysis is most useful in patients un-
dergoing major surgery, especially if intermittent posi-
Oxygen tive-pressure ventilation is used as part of the anaesthetic
The measurement of inspired 0 2 concentration is use- technique. Gas monitors are non-invasive and very easy
fui as an assurance that the patient is not breathing a to attach to patients and can easily form part of a routine
hy poxic gas mixture . This can be especially useful monitoring system in thea tres where they are available.
w hen using a rebreathing system as it can allow the safe
use of N 20. The meas urement of inspired 0 2 concen-
tration combined with blood gas analysis o r pulse ARTERIAL BLOOD PRESSURE
oximetry can a iso be usefu! in assessing the severity of
pulmonary dysfuncti on. When used with pulse oxime- Arterial blood pressure is one of the most useful
try, the rn ini mum concentration of inspi red 0 2 req uired measures of cardiovascular function available to the
to produce an Sp02 of >95 % can easily be determined anaesthetist. Unfortunately it cannot be appreciated
and changes used as an indicator of worsening or withoutmonitoring equipment of sorne ki nd. There are
improving respiratory function. Wh en used with blood two methods of measuring blood pressure which are
gas analysis, the difference in alveolar/arterial 0 2 widely used in clinicat practice - direct and indirect.
tension can be calculated using a derivation of the
alveolar air equation: Direct blood pressure measurement
This technique involves the placement of a cannula into
a peripheral artery. In the dog, the dorsal metatarsal
\\ hac PAO: hi alvcolar PO:. P10~ is inspir~d PO: :md Pa CO: i~ :1ncrial PO:.
artery and femoral artery on the hindlimb or the pal mar
artery on the forelimb are the most common sites for
PA0 1 is then used in a second equation: cannula placement. The middle auricular artery can be
used in breeds that have large ears, e.g. Basset Hound.
In the cat, the femoral artery is the most common site.
The cannula is connected to a pressure transducer via a
In normal animais this value should be <15 mmHg colurnn of heparinized saline. The transducer can be a
(2 kPa), but it becomes larger if lung function flex ible m embrane fluid/air inte rface (e.g. th e
deteriora tes. Pressureveil, Figure 5.6) connected to a Bourdon pres-
sure gauge, or an electro nic strain gauge co1mected to an
Nitrous oxide electronic monitoring deviee. The transducer is zeroed
The measurement ofN 20 concentration is use fu! at the at the leve! of the right atrium. Both methods g ive a
end of anaesthesia, when it can be used to monitor the continuous reading of blood pressure.
decreasing expired concentration of N20 when the The Pressureveil measures mean blood pressure,
pati ent is breathing lOO% 0 2 . If the patient is not but ca1mot respond to the change in pressure over the
disconnected until the expired N 20 concentration has cardiac cycle rapidly enough to give an indication of
s ubstantially decreased then there is no ris k of diffu- systolic or diastolic pressure. A strain gauge trans-
s ion hypoxia in the early postoperative period. ducer responds instantly to changes in pressure and
Il
Patient Monitoring 51

Problems
The problems with direct blood pressure measurement
are most! y those of arterial cannulation. There is poten-
tial for accidentai displacement of the catheter and
subsequent haematoma formation. Pressure should
always be a pp lied to an artery for 5 minutes afterfailed
attempted cannulation or removal of a cannula, to
allow the wall to seal through thrombus formation. In
addition the accidentai intra-arterial injection of drugs
through an arterial catheter can be disastrous. Agents
such as thiopentone can crystallize out of solution after
arterial injection and can block the arterioles leading
Figure 5.6: Direct arterial blood pressure measurement
from the artery causing ischaemia and nec rosis of the
using a Pressureveil system connected to the dorsal
metatarsal artery of a dog. Note thal the saline/air interface area served by that vesse!.
should be placee/ at the levet of the right atrium. Indirect arterial blood pressure measurement has
few complications, but can give inaccurate results if
should be connected to the cannula using narrow non- attention to detail is not paid when performing this
compliant tubing to preventdistortion of the signal due procedure. The width of the occlusive cuffused affects
todamping orresonance (ringing). Systolic and diastolic the result. In general, the wider the cuff the lower will
pressures are taken as the cyclic maximum and mini- be the values obtained. The ideal cuff width is usually
mum pressures respectively, and mean pressure is quoted as 40% of .t he circumference of the limb to
calculated using the area under the curve (integral) of which it is a pp lied, but this is a compromise as the ideal
the waveform. Interpretation ofthe systolic and diastol ic width also varies with the pressure range being meas-
pressure is complicated by the frequency response ured. With automatic techniques attention s hould also
characteristics of the catheter/transducer system and be pa id to the correct rotation of the cuff compared to
the location of the catheter. Nevertheless, trends in the artery. Most cuffs have a mark which should be
these pressures are useful clinicat tools. placed directly over the artery. Indirect blood pressure
measurements become more difficult in very small
Indirect blood pressure measurement animais and when the patient is hypotensive. When
There are severa! variations of this technique ali of using a manual method the qua lity of the sounds s hould
which are based on the occlusion of blood flow to an give an indication that the technique is working prop-
extremity by the inflation of a cuff tourniquet. Any of erly. Mechanical methods tend to fa il by giving results
the limbs orthe ta il can be used. Pulsatile flowofblood which are Jess and Jess accurate. When using s uch a
is detected either by pulsatile pressure changes in the method the correct function of the monitor can be
cuff itself (osci llometric) or by the placement of a flow checked by counting the pulse rate and comparing this
transducer over an artery distal to the cuff. The trans- to the pulse rate given by the monitor. The stability of
ducer is usually an ultrasound probe and either detects the results over severa! estimations cana Iso be used as
flow of red cells through the artery (Doppler) or an indicator of correct functi on.
movement of the arterial wall (Arteriosonde). Indirect
blood pressure monitors give intermittent readings of Significance of information
blood pressure. Arterial blood pressure monitoring gives information
The cuff is inflated un til ail flow through the artery about the ability of the heart to pump blood a round the
ceases and then deflated slowly until the first flow is body a·nd the fluid balance of the patient. Blood flo w to
detected. The pressure at which blood flow recom- the major organs of the body is autoregulated across a
mences is ta ken as systolic blood pressure. As the cuff range of mean blood pressures from about 60 mrnHg
is further deflated, diastolic and mean blood pressure (8 kPa) to about 120 mmHg (16 kPa). When blood
are meas ured. Oscillotonometric deviees record mean pressure falls below titis range, blood flow to major
blood pressure as the pressure at which the pulses in the organs is compromised and there may be serious long-
cuff are ma ximal and diastolic pressure as the pressure and short-term consequences. Such a reduction in
below which they disappear. When using a flow trans- organ flow will result in the accumulation oflactic a cid
ducer, diastolic pressure is taken at the point when in the tissues and the development of acidosis. Long-
blood flow occurs throughout the cardiac cycle, and term consequences of reduced organ blood flow can be
mean pressure is calculated as diastolic pressure plus seen due to ischaemic damage to tissues that have
one third of the difference between systolic pressure undergone periods of inadequate 0 2 delivery. The
and diastolic pressure: most common consequence ofthese in the dog is rena l
failure, the onset of wllich may be precipitated or
Mean Diastolic + ( Systolic pressure ; diastolic pressure ) hastened by such a period of reduced renal blood flow.
pressure pressure Changes in blood pressure over time can be used
52 Manual of Small Animal Anaesthesia and Analgesia

in conjunction with heart rate to help diagnose the


(a)

r:=::-
development of inadequate anaesthesia, anaesthetic
agent overdose, hypovolaemia and overhydration
(Figure 5.7). ISOol j'\____ j'\____[\_
When monitoring arterial blood pressure using a
direct method with an electronic monitor, much infor- ··"·~
mation can be gained from the shape of the trace in
addition to the absolute values of systolic, diastolic and
mean pressures. The rate of rise of the waveform in the (b) 150
0.5 s
early systolic period is the best clinical indicator of
ventricular contractility. The degree of curvature in the
mm Hg
diastolic part of the waveform gives an indication of
the presence of hypovolaernia (Figure 5.8).

Usefulness
Arterial blood pressure monitoring is not a technique (c) 150
that is widely used on all cases. This is because all the
techniques available to monitor blood pressure require 1s

a degree of ti me and effort to set up and take measure- mm Hg


ments. Blood pressure gives a direct indication of the
adequacy of cardiovascular function, which can re-
spond very rapidly to changing situations. As such, it
is extremely useful in patients with significant cardio-
vascular disease and patients undergoing major sur- (d) 150

gery. Like any technique, it becomes easier and also


quicker and more accurate with practice, and so if a 0.5 s
mmHg
blood pressure monitoring deviee is purchased, it
should be used on a regular basis. Staff will th en leam
both how to set up and use the system and the signifi-
cance of the information obtained. With increased
farniliarity, blood pressure monitors can be used on a Figure 5.8: Recordings of arterial blood pressure taken
wider population of patients and should become rou- using an electronic pressure transducer connected ta an
arterial cannula. (a) Normal arterial blood pressure. Note
tine monitoring equipment.
brisk increase in the early systolic period and 'springy'
baseline in the diastolic period. (b) The large pulse pressure
and flat baseline indicate hypovolaemia. This dog has /ost
considerable blood from an arterial bleed during thoracic
surgery. (c) The slow rate of rise in the early systolic period
Inadequate Anaesthetic indicates myocardial depression in this case due to relative
halothane overdose. (d) Combined hypovolaemia and
anaesthesia agent overdose
myocardial depression. This is the same case as in Figure
5.8b. When this recording was made, the ongoing blood loss
was compromising oxygen delivery due ta falling packed cell
volume and reduced perfusion.

CENTRAL VENOUS PRESSURE

Central verrous pressure (CVP) is ta ken as the pressure


Hypovolaemia Overhydration in the great veins within the thoracic cavity. In corn-
mon with arterial pressure, CVP is measured with
reference to a zero point, taken to be the leve! of the
right atrium. This is approximated by the leve! of the
manubrium in lateral recumbency and the scapulo-
humeral joint in patients on their backs. In order to
measure CVP, a cannula must be inserted into the
jugular vein so that its tip lies beyond the thora cie inlet.
This is connected to a pressure transducer usually in
Figure 5. 7: Changes in heart rate (solid Une) and arterial the form of a saline manometer (Figure 5.9).
blood pressure (dashed tine), which occur over tùne. Central verrous pressure is the first cardiovascular
Patient Monitoring 53

antibiosis to pre vent nosocornial infection. The collec-


tion system and bladder are both emptied and the urine
that accumulates measured over a known period (usu-
ally 30 minutes to 1 hour). A reduction in urine
production to below 1 ml/kg/h indicates that renal
perfusion is reduced or that the patient is dehydrated
and is conserving water by resorption of glomerular
filtrate. Both circumstances indicate hypovolaemia or
cardiovascular collapse and can lead to the develop-
ment of acute renal failure if not remedied.
Urine output is usually only measured when a uri-
nary catheter is placed for other reasons. In such animais
it can be used as a reasonable medium-term indicator
that arterial blood pressure is sufficient to maintain renal
perfusion. It is also invaluable in the treatment of acute
renal failure where the renewed production of urine
gives evidence of response to treatrnent.

BLOOD GAS ANALYSIS

Blood gas analysers measure the pH of the blood and


the tension of 02 and co2and can also calculate other
variables such as plasma bicarbonate concentration,
total plasma co2, haemoglobin saturation and base
excess. More modem machines can often perform
additional measurements su ch as concentration of so-
dium, potassium, chloride and ionized calcium, and
Figure 5.9: Measurement of central venous pressure (CVP) haematocrit. Traditional blood gas monitors have elec-
from a Dobermann during ventral cervical intervertebral
diskfenestration. Note that the JO cm mark is usedas a zero (CVP
trodes that are placed in contact with the blood and rely
can be negative) and placed at the Levet of the right atrium. on the setting up of an electrical half cell to perform
their measurements. These machines are expensive
variable to alter in response to changes in fluid balance and require frequent skilled maintenance in arder to
and as such gives a good indication of the hydration remain functioning accurately. Recently, however,
status of the animal and of the ability of the heart to blood gas analysers using newer technology, such as
pump blood. The normal range in the dog and cat is disposa ble modules, have become available. These are
large, making single readings of limited value, but a cheap to buy and require little or no maintenance.
small change over time can be interpreted as an altera- Despite the higher sample costs of these units they
tion in cardiovascular function. A low (or fa !ling) CVP have brought blood gas analysis within the reach of the
occurs when the central verrous reservoir is depleted, general practitioner.
and so indicates hypovolaemia. A high (or increasing) The blood gas machine utilizes samples of
CVP occurs when the central verrous reservoir is heparinized blood. The blood samples should be
weil filled, and so can indicate hypervolaemia or withdiawn anaerobically and analysed promptly so
cardiogenic-cardiovascular insufficiency. Central that the measured values reflect the actual gas
verrous pressure can be a valuable a id in differentiating tensions in the blood and not ones that have been
low arterial blood pressure due to hypovolaernia from altered by contact with room air. Blood gas analysis
low arterial blood pressure due to heart failure. can be performed on any blood sample, but it is usual
to use arterial blood wherever possible. Arterial blood
is preferred because it can provide information about
URINE OUTPUT the ability of the lungs to oxygenate the blood and
also because it is mixed and so can be taken from any
Urine output is measured over a period of time by artery. Venous blood can only provide information
collecting urine from the bladder. This is usually about the tissues that are drained by the vein from
performed in a serni-continuous manner in patients which the sample is taken~
with an indwelling urinary catheter and a closed col-
lection system. Careful attention should be paid to Significance of information
sterile technique when setting up and managing such a The results of blood gas analysis can provide invalu-
system, and the patient should normally be receiving able information about the oxygenation and acid/base
54 Manual of Small Animal Anaesthesia and Analgesia

status of the patient. The detailed interpretation of They allow trends in patient variables to be
blood gas measurements can be complex as ali the noticed at an early stage. For example, a sudden
results are interrelated. change in heart rate from 100 beats per minute to
60 beats per minute should be obvious to anyone
Problems monitoring an anaesthetic. If this same change
Ordinarily, blood gas analysis requires a sample of occurs over 10 or 20 minutes then it is much Jess
arterial blood. Taking an arterial blood sample is obvious but will be immediate! y visible if the
relatively easy, but complications such as haematoma heart rate is recorded every 5 minutes. Such
or bru ise formation at the site of sampling can occur detection of trends will allow the anaesthetic to
without careful attention to technique. In particular, be adjusted to compensate for this s lowing heart
pressure should be applied to the site for severa! rate sooner than would otherwise be the case
minutes after sample collection to allow the vesse! to An archive of anaesthetic records will enable
seal. If it is likely that multiplesamples will be required similar situations that occur in a number of cases
from a case then the placement of an arterial cannula to be directly compared to each other. For
should be considered. example, if a change is made in routine
anaesthetic protocols and occasional instances of
Usefulness hypoventilation occur, then the records from
Blood gas analysis is useful in the management of severa! cases can be inspected and can give a
critical patients and those presenting for major sur- detailed picture of the circumstances surrounding
gery. Ace urate assessment of the ability of the lungs this complication. This may highlight the reason
to oxygenate the blood and the acid/base status of for the problem, which can then be rectified
the animal is invaluable in the evaluati on of a • They can concentrate the mind of inexperienced
case. Specifie treatment can be platmed from the personnel and improve their standard of patient
results of initial blood gas analysis and the response monitoring. In this case the improvement in
to this treatment can be monitored by taking further anaesthetic monitoring cornes through paying
blood gas samples. more attention to the patient and the record itself
li is of secondary importance
• It is increasingly common for courts to become
RESPIRATORY AND CARDIAC involved in disputes involving the management
'BLEEP' MONITORS of veterinary patients. In cases where the
anaesthetic management of a case needs to be
Many monitors are available that detect the presence of defended, an anaesthetic record is of enormous
an electrocardiograph or movement of respiratory ga ses, worth both as a reminder of the details of the
and that bleep with respiration or with an ECG com- individual case and as evidence of the general
plex. In the past these monitors have found a place in standard of care given by the veterinary practice.
many practices, but they should be treated with ex- To be admissible as evidence, an anaesthetic
i treme caution as they provide very little information record must be contemporaneous i.e. it must
about the physiological state of the patient and it is have been made at the same time that the
dangerous to rely on them. The respiratory monitors anaesthetic was given.
usually respond to a change in temperature at the end
of the ETT. This provides information about the rate of
respiration, but nothing about the Vt. In addition, it is ELECTRICAL SAFETY
possible for these monitors to continue to bleep in ti me
with the heart rate in patients that have undergone When any electrical equipment is connected to a
respira tory arrest. The cardiac monitors res pond to the patient there is a risk of injury to the patient from
ECG and so give no information about the mechanical leakage of electrical current. This risk can be mini-
function of the heart. In addition, they can respond to mized by ensuring that the equipment used is of a
sorne arrhythmias as 'normal' complexes and give no medical standard and is electrically isolated from the
infonnation about the ki nd of arrhythmia present when patient. It is also important to ensure that the equip-
an irregularity is detected. ment is regularly serviced so that faults which may lead
to a leakage of current through the patient do not go
undetected. Leakage of electrical current can lead to
ANAESTHETIC RECORDS burns developing at the contact or earthing point of the
patient and can lead to cardiac arrest if sufficient
In arder to get the best out of monitoring equipment it current passes across the heart. In the UK, electrical
is advisable to keep a written record of every anaes- monitoring equipment that makes an electrical con-
thetic procedure. Anaesthetic records are useful for nection to the patient is categorized into two safety
four main reasons: standards: CF is used for equipment that has a direct
il
Patient Monitoring 55

intracardiac connection and must have a leakage cur- ate to the expected complications of the patients en-
rent of <50 IJA, even if a single fault develops, and B countered and will be used often enough for the staff to
or BF is only suitable for non-cardiac or surface become familiar with its function and skilled at inter-
connection and must have a leakage current of < 500 preting the information given.
IJA, even if a single fault develops. In the USA, the
Ieakage current for an ECG that uses surface electrodes
should not exceed 300!-IA. These standards are not CHOOSING A MONITOR FOR A CASE
obligatory for equipment used in veterinary medicine,
but it is sensible to ensure that any equipment pur- When selecting a monitor for a patticular case, the
chased conforms to the appropriate safety standard. selection will be made from th ose available within the
practice. It is not always appropriate to attach every
monitor to every patient as this may lead to prolonged
WHICH MONITOR TO BUY anaesthetic times for minor surgical procedures and
can actually reduce the monitoring efficiency of inex-
As more ambitious surgical procedures on high-risk perienced staff. At the same time it should be remem-
patients are undertaken in veterinary practice, the need bered that for the best to be gained from a monitor, it
fo r adequate patient monitoring increases. When con- should be familiar to staff and it should be used on a
sidering which anaesthetic monitors to bu y it is impor- regular basis.
tant to bear in rnind the case Joad as weil as the
expertise of the staff operating the monitor. It is useful
if an overall idea of the ideal or desired monitoring set- FURTHER READING
up can be gained before the first monitor is purchased
Edwards NJ (1987) Bo!10n 's Handbook of Canine and Feline
so that possibilities can be assessed both in terms of Electrocardiography, 2nd Editiou. WB Saunders, Philade lphia
their immediate usefulness and how they will fit in to Moy le JTB ( 1994) Pulse Oximetry. BMJ Publishing Group, London
D'Flaherty D (1994) Capnography. BMJ Publishing Group, London
a broader picture. An ideal monitoring deviee or com- Parbook GD, Davis PD and Parbrook EO (1990) Basic Physics and
bination of deviees will provide information appropri- Measurement in Anaesthesia. Butterworth-Heinemann, Oxford
PARTTWO

The Pharmacological Basis


of Anaesthesia and Analgesia
Analgesia 59

CHAPTER SIX

Analgesia
Avril E. Waterman-Pearson

INTRODUCTION • There is a limited number of licensed products


available for use
Pain is a universal experience and, although everybody • There are reservations about the potential side
knows what it feels like, it is very much more difficult effects of analgesics.
to define. Humans can express and describe the sensa-
tions they experience, and these descriptions are well Analgesic drugs are often withheld because the
accepted. Assessment in animals is much more diffi- clinician is not absolutely sure that the animal is
cult. One must rely on the observation of overt signs experiencing pain, and yet that same clinician may
and the correct interpretation of these signs, for it is administer antibiotics without proving the presence of
only when pain is recognized that steps can be taken to bacterial contamination or infection. Precisely be-
alleviate it. cause pain is difficult to assess, a liberal attitude to the
use of analgesic drugs should be maintained;
overtreatment may occur, but the adverse consequences
ADVANTAGES AND DISADVANTAGES of this are minimal compared with the distress caused
OF PAIN by withholding pain relief. It is sometimes suggested
that analgesics should be withheld so that the protec-
The ability to feel pain has clear survival advantages: tive function of pain is maintained. However, provided
limiting the extent of an injury, encouraging rest and that effective measures are taken to immobilize or
healing of the injured area and ensuring that the indi- protect damaged tissues, and competent surgical tech-
vidual learns to avoid noxious stimuli in the future. niques are employed, the abolition of pain rarely causes
Ongoing pain, however, has no benefit and many problems. It is hard to concede that leaving a patient
disadvantages. Ongoing pain: without pain relief can ever be advantageous.

• Is distressing for the animal; postoperatively,


dogs and cats in pain are dull and depressed and ASSESSING PAIN IN DOGS AND CATS
do not recover as well as might be expected
• Provokes an enhanced stress response and increases Humans can express and define the sensations they are
catabolism causing delayed wound healing experiencing and can localize the site of the pain. In
• Depresses food intake animals one must rely on the observation of behav-
• Results in impaired respiration. Especially after ioural cues and their correct interpretation. The judge-
upper abdominal or thoracic surgery, animals are ment of pain in animals is bound to be based on
more prone to pulmonary atelectasis, hypoxia, personal experiences and, although such an anthropo-
hypercapnia and the retention of mucus and morphic approach is potentially dangerous, it is rea-
sputum, due to a reluctance to cough. This sonable as a first line of approach. Animals probably
increases the risk of pneumonia have no psychological expectation of pain, and so the
• Can lead to self-mutilation confounding influence of anticipation is removed.
• Causes sensitization of the central nervous Animals are generally less demonstrative about their
system (CNS). pain than humans, not least because for those animals
that are hunted there is a survival advantage in not
The reasons for the relative neglect of analgesia by displaying abnormal behaviours overtly as this would
veterinarians may be because: attract the attention of predators.
Changed responsiveness to human contact is often
• Pain in animals is difficult to recognize a first indicator that the animal is in discomfort. Ag-
• There are misconceptions about the use of gression and avoidance of human contact may in-
analgesic drugs, especially opioids crease, or conversely some animals may seek excessive
60 Manual of Small Animal Anaesthesia and Analgesia

human reassurance. Acute postoperative pain pro- This scoring system combines visual appraisal
vokes signs of guarding and vocalization, especially if of spontaneous behavioural signs indicative of
the painful area is manipulated. Lack of vocalization, pain with a qualitative assessment of response to
however, should not be interpreted as lack of pain. palpation of the affected area. If the animal is in
Moderate discomfort often leads to attempts to bite pain, palpation can produce an exaggerated behav-
or scratch the area, while deafferentation pain (e.g. ioural response such as aggression, vocalization
following peripheral nerve or spinal cord injury) can or avoidance. Such an interactive method of assess-
give rise to self-mutilation. Increased restlessness is ing pain, which includes handling the animal, allows
often a feature of postoperative discomfort, especially a far more accurate assessment of the severity of
if the source of the pain is visceral, while extreme the discomfort than can be ascertained from mere
somatic pain leads to reluctance to move. This may be observation.
a reflection of the poor localization of visceral pain as
opposed to pain of orthopaedic origin.
More chronic localized sources of pain such as limb MECHANISMS OF PROCESSING
injuries give rise to stiffness, difficulty in walking or NOCICEPTIVE INFORMATION
rising, changes in gait and obvious avoidance re-
sponses if the affected area is manipulated. Chronic
visceral pain is less easy to quantify – low-grade The ‘pain pathway’ can be split into three principal
discomfort tends to reduce the animal’s general well components:
being and demeanour, while increasing pain levels
lead to abnormal postures and guarding or straining. • Peripheral tissue nociceptors detect the stimulus
Disturbances to the normal sleep pattern, with a and permit transmission of the nociceptive
dog sleeping less, is also an indicator of discomfort. signal via primary afferent nerve fibres to the
Thoracic pain makes dogs and cats reluctant to lie spinal cord or cranial nerve nuclei. There are
down or sleep despite obvious exhaustion. Reduced four types of peripheral nociceptors: high- and
grooming and eating behaviour are often manifesta- low-threshold mechanoreceptors,
tions of more chronic pain. thermoreceptors and polymodal nociceptors,
Cats in pain are less vocal and demonstrative than while visceral receptors are activated by
dogs and tend to be less active: they sit unresponsive dilation or ischaemia. Nociceptive signals are
and hunched in sternal rather than in curled lateral conveyed by primary afferent axons (slowly
recumbency. The most severe pain may cause cats to conducting unmyelinated C-fibres or small
vocalize spontaneously, although more usually growl- myelinated Aδ nerve fibres).
ing or hissing is reserved for pain provoked by manipu- • Signal processing occurs in the spinal cord or
lation of the wound site. Aggression and resentment of brainstem before transmission to supraspinal
handling is a common manifestation of pain in cats. structures. The primary afferent axons enter the
Self-mutilation is rare but may be provoked by intense spinal cord via the dorsal root into the dorsal
neurogenic pain. horn and terminate mostly in lamina I (Aδ nerve
fibres) or lamina II (C-fibres). There are two
classes of nociceptive neurons within the dorsal
A SCORING SYSTEM FOR PAIN horn:
– Wide dynamic range neurons which respond
A useful way of learning how to assess pain is to use a mainly to innocuous stimuli, unless the
simple scoring system. A four point numerical rating stimulus level is great (i.e. noxious), when
scale can be used: the frequency of their discharge is increased
– Nociceptive specific neurons which respond
• 0 – No pain, no overt signs of discomfort, no exclusively to noxious stimulation.
resentment to firm pressure Pain behaviours correlate better with firing in
• 1 – Some pain, no overt signs of discomfort, wide dynamic range neurons than in nociceptive
resentment to firm pressure specific neurons
• 2 – Moderate pain, some overt signs of • After further processing at supraspinal sites, the
discomfort, made worse by firm pressure signal induces the conscious perception of pain.
• 3 – Severe pain, overt signs of persistent
discomfort, made worse by firm pressure. There are, in addition, various intrinsic segmental,
spinal and supraspinal endogenous mechanisms
Postoperatively, scoring should be carried out at for inhibiting the transmission of the nociceptive
1 and 4 hours, and the scores should be recorded. The signals which are mediated by endogenous neuro-
aim should be to keep scores in the 0 or 1 category transmitter systems (opioid, serotonergic, choliner-
at all times. gic, adrenergic).
Analgesia 61

CNS sensitization Peripheral sensitization differs from central


The appreciation of pain does not simply involve a sensitization because it enables low intensity stimuli to
moment by moment analysis of afferent noxious produce noxious signals by activating sensitized
input relayed by a hard-wired transmission system, nociceptors and primary afferents, whereas central
but is more a dynamic process that is influenced sensitization represents an abnormal interpretation of
by past experiences. The system has great plasticity, information from low-threshold sensory fibres, their
and is able to change over time according to experi- input now interpreted as pain.
ence. This concept is not new. In 1883, Sturge The clinical implications of this hypersensitivity
proposed that peripheral injury triggered a change in are that:
the excitability of the CNS so that normal inputs
evoked exaggerated responses leading to pain • Once pain is established, analgesic drugs, for a
hypersensitivity, and in 1913, Crile made similar given dose, are much less effective, i.e. pain is
observations. more difficult to control
Clinical pain can be classified as inflammatory or • The pain is perceived to be greater by the animal.
neuropathic and is distinguished from physiological
pain by the presence of pathological hypersensitivity. Thus, the evidence is overwhelming that pain should
Inflammatory pain relates to peripheral tissue damage, be prevented rather than merely treated. By preventing
and neuropathic pain relates to a damaged CNS. Both the surgical afferent barrage from entering the spinal
are characterized by changes in sensitivity, such that cord, these changes in spinal nociceptive processing
stimuli that are not normally perceived as painful can be prevented and, thus, the severity of postopera-
become painful (allodynia) and an exaggerated re- tive pain can be markedly decreased. The concept of
sponsiveness to a given noxious stimulus (hyperalge- ‘pre-emptive analgesia’ is the administration of anal-
sia) develops and spreads to uninjured tissue (secondary gesics preoperatively to reduce the severity of postop-
hyperalgesia). erative pain.
This sensitization can occur at either or both pe- It has been shown experimentally in rats (Woolf and
ripheral and central levels: Wall, 1986) and clinically in dogs (Lascelles et al.,
1997) that preinjury treatment with opioids prevents or
• Peripheral sensitization develops because of an markedly decreases the development of central hyper-
increase in the sensitivity of nociceptors as a sensitivity, but these treatments are far less effective if
result of exposure to a ‘soup’ of inflammatory administered after the injury is initiated. Local analge-
mediators (bradykinin, prostaglandins, sics (Coderre et al., 1990) have a similar protective
leucotrienes, 5-hydroxytryptamine (5-HT), effect, both experimentally and clinically, e.g. phantom
histamine, substance P, thromboxanes, platelet limb pain after amputation in humans (Bach et al., 1988).
activating factor) released by tissue injury. These
inflammatory changes may also induce normally
unresponsive (‘sleeping’) nociceptors to become STRATEGIES FOR
active. The net result is an increase in firing rate CONTROLLING PAIN
of afferent nerve fibres
• Central sensitization develops as a result of At this point it is important to make a distinction
changes in the spinal cord. An activity-dependent between the prevention of sensitization of the CNS and
increase in excitability of dorsal horn neurons the alleviation of postoperative pain. Pre-emptive an-
develops which outlasts the nociceptive afferent algesia may block the development of sensitization,
inputs (Woolf, 1983). This produces secondary but it cannot eliminate postoperative pain; additional
hyperalgesia, i.e. there is a spread of measures are still required to ensure a comfortable
hypersensitivity to uninjured tissue. ‘Central recovery. The aim of pre-emptive analgesia is solely to
hypersensitivity’ results in a modified response reduce the severity and duration of postoperative pain
to subsequent afferent inputs, which lasts and to minimize the chances of a persistent pain state
between 10 and 200 times the duration of the becoming established.
initiating stimulus (Woolf and Chong, 1993). Effective analgesia depends on giving the correct
There are several receptors involved in the combination of drugs in effective doses by the most
mediation of these changes in the spinal cord, appropriate route, i.e. balanced analgesia. Since indi-
one of the most significant clinically being the viduals vary in their response to surgery, the adequacy
N-methyl-D-aspartate (NMDA) subtype of the of pain alleviation can only be determined by continual
glutamate receptor. assessment of the animals and adjustment of the treat-
ment protocol as necessary. Effective pain control is
Central sensitization is responsible for some of the not achieved by waiting until the animal shows overt
changes in the zone of primary hyperalgesia, but all of signs of pain before giving another dose of analgesic.
the changes in the zone of secondary hyperalgesia. The aim must always be to provide a completely
62 Manual of Small Animal Anaesthesia and Analgesia

pain-free postoperative period, and this is best achieved Opioids


by having a planned protocol of drug(s) administration All opioids are chemically related and in the UK most
beginning preoperatively and continuing intra- and are controlled drugs under the Misuse of Drugs Act,
postoperatively, using a rational combination of two or 1971, which governs their purchase, storage and use.
three of the main types of analgesic drugs. Opioids are similarly controlled in the USA by the
The optimum form of pain therapy should be Controlled Substances Act, 1970. Most countries have
continuous pre-emptive analgesia, continuously comparable legislation for regulating the use of opioids.
preventing the establishment of sensitization. The All opioids have a similar mode of action, although
administration of opioids or local anaesthetic drugs their activity at the various opioid receptors varies.
blocks central sensitization while non-steroidal anti- Currently, four opioid receptors have been cloned:
inflammatory drugs (NSAIDs) reduce the severity of OP1(δ), OP2(κ) OP3 (µ) and the orphan opioid receptor
the peripheral inflammatory response. (ORL1). The latter seems to be linked to the endo-
Clinically, the aim should be to provide balanced genous peptide nociceptin, which seems to have anta-
analgesia using a combination of an opioid and an gonist properties. Most opioids used clinically are
NSAID. Their combined use is more effective than selective for the µ receptor and mimic the effects of
using either drug alone. endogenous opioids in the CNS and possibly peripher-
ally in inflamed tissue. There are two types of opioid
drug used clinically: full agonists and partial agonists.
ANALGESIC AGENTS Full µ-agonists, such as morphine, have a predictable
profile of activity, a high ceiling of effect and provide
Local anaesthetic agents the most reliable degree of pain relief postoperatively.
Local anaesthetics can produce complete pain relief by Although partial µ-agonists (or κ-agonists) can be very
blocking all sensory input from the affected area. It is effective, they are less reliable against a wide range of
a reasonable view that the risk of CNS sensitization types of pain, have a poor dose/response relationship
after surgery is such that some form of regional anaes- and, should they fail to be effective, increasing the dose
thesia should always form part of any anaesthetic is not likely to increase the degree of analgesia; chang-
regimen, but in practice the site of injury/surgery will ing to another opioid can then prove difficult.
determine the feasibility of using regional anaesthesia The major effects of opioids are:
to control pain. While certain sites lend themselves to
the use of local blocks (intercostal blocks after • Analgesia
thoractomy, mandibular nerve block after • Sedation in low doses
mandibulectomy), other sites can be more difficult to • Euphoria/excitement in high doses (especially in
desensitize. Local anaesthetics may also be employed cats)
topically, e.g. on the mucosa following nasal or rectal • Respiratory depression. This is potentially one of
surgery; EMLA (Eutectic Mixture of Local Anaesthet- the most serious side effects in humans, but it is
ics) cream is most effective in reducing the pain rarely a clinical problem in dogs and cats unless
associated with venepuncture in restless cats. Brachial the drugs are combined with other potent
plexus blocks are technically difficult to master, but respiratory depressants during general
provide excellent pain prevention for major surgery of anaesthesia. Opioids should be used with caution
the forelimb and should be mandatory before forelimb in animals with respiratory disease, but since
amputation to minimize the risk of possible phantom thoracic pain can cause impairment of adequate
limb pain. Similarly, extradural (epidural) analgesia is respiratory excursions, their use can be beneficial
highly recommended as an adjunct to hindlimb sur- • Cough suppression
gery and is essential if amputation is contemplated. • Nausea, vomiting and defecation
Local anaesthetics produce analgesia when given in • Gut sphincter stimulation/constipation. The use
small doses intravenously, but are potent proconvulsants of most opioids should be avoided in animals
and can induce marked myocardial depression and with biliary obstruction or pancreatitis because
cardiac dysrhythmias when administered by this route. they cause an increase in tone in the sphincter of
The local anaesthetic drug chosen for postopera- Oddi, with the exception of pethidine, which has
tive pain relief should ideally have a long duration of a spasmolytic action on this sphincter
action and, therefore, bupivacaine (onset 15 minutes, • Oculomotor nucleus stimulation. High doses tend
duration of action 4–6 hours) or ropivacaine are the to cause pupillary dilation in cats, which can make
drugs of choice, although they are not licensed for the assessment of neurological status difficult.
veterinary use. Lignocaine, which is licensed, may be
used during surgery for a more immediate effect. Drug absorption is more reliable and, therefore,
Safe maximum doses are: 4 mg/kg lignocaine or 1–2 drug efficacy is better if opioids are administered
mg/kg bupivacaine. These doses should be diluted to the intramuscularly; however, some animals violently re-
volume required to facilitate the application of the block. sent intramuscular injections, and extensive clinical
Analgesia 63

Drug Dogs Cats


Pethidine Dose: 3.5–10 mg/kg i.m. or 10–15 mg/kg s.c. 5–10 mg/kg i.m. or 10–15 mg/kg s.c.
L CD L CD
Duration: 2.5–3.5 hours Duration: 2 hours
Morphine* Dose: 0.1–0.5 mg/kg i.v., i.m. or s.c. Dose: 0.1–0.2 mg/kg i.m. or s.c.
NL CD NL CD
Duration: 4–6 hours Duration: 6–8 hours
Fentanyl Dose: 0.002–0.005 mg/kg i.v. or i.m.
NL
Duration: 20–30 minutes
Methadone Dose: 0.1–0.25 mg/kg i.v., i.m. or s.c.
NL CD
Duration: 4–6 hours
Oxymorphone Dose: 0.05–0.2 mg/kg i.v., i.m. or s.c. Dose: 0.05–0.4 mg/kg i.v., i.m. or s.c.
L (USA); CD L (USA); CD
Duration: 2–4 hours Duration: 2–4 hours
Buprenorphine Dose: 0.010–0.020 mg/kg i.m. or s.c. Dose: 0.005–0.020 mg/kg i.m. or s.c.
L CD NL CD
Duration: 6–8 hours
Butorphanol Dose: 0.2–0.5 mg/kg i.v., i.m. or s.c. Dose: 0.2–0.8 mg/kg i.m. or s.c.
L L2
Duration: 1–2 hours Duration: 2–4 hours
Pentazocine Dose: 2–3 mg/kg i.m. Dose: 2–3 mg/kg i.m.
NL NL
Duration: 1.5–2 hours Duration: 2–3 hours
Naloxone Duration: 0.04–1.0 mg/kg i.v., i.m. or s.c. Duration: 0.04–1.0 mg/kg i.v., i.m. or s.c.
(antagonist) NL
Figure 6.1: Doses and routes of administration of opioid analgesics used in the dog and cat.
L=licensed; CD=controlled drug; NL=not licensed in the UK. * = Approved for veterinary use in the USA.

experience confirms that the subcutaneous route can Papaveretum (‘Omnopon’)


be successfully employed in these situations, as long as Papaveretum is a preparation containing all the alka-
a higher dose is used. loids of opium, with 50% morphine content. The
Doses and routes of administration are shown in presence of the other alkaloids seems to reduce the
Figure 6.1. incidence of nausea and vomiting and improve seda-
tion. Doses are roughly double those for morphine.
Morphine
Morphine is still the analgesic of choice for the most Pethidine (Meperidine)
severe pain in dogs and cats and is the benchmark by Pethidine is a synthetic compound with approximately
which other drugs are assessed. It is a pure -agonist and 1/10 the potency of morphine. It is a µ-selective
is a potent analgesic and a good sedative, but is not agonist, but unlike morphine it is devoid of adverse
licensed for use in animals in the UK. However, it can gastrointestinal effects. The clinical value of pethidine
cause nausea and vomiting, especially when used lies in its relative lack of unpleasant side effects and its
preoperatively. Following administration, the onset of excellent sedative and spasmolytic properties. Its fast
action is not rapid, but its duration of action is longer onset of action and its predictability make it a very
than its plasma half-life would suggest. Morphine is useful analgesic. It has a relatively short duration of
metabolized by conjugation, so its half-life is longer in action, although postoperatively this may not be such
the cat than in the dog (3 hours versus 60 minutes). Much a drawback. There is no nausea or vomiting and its
of the notorious reputation of morphine in cats resulted atropine-like structure gives it spasmolytic properties,
from its use in gross overdosage, based entirely on the which makes it very useful for visceral pain. However,
work of Joel and Arndts (1925), who used a dose of 20 it does induce histamine release if given intravenously,
mg/kg. It is certainly a safe drug to use in this species. which leads to profound hypotension.
64 Manual of Small Animal Anaesthesia and Analgesia

Following anaesthesia and surgery in old dogs, or certainly the case in the cat, where the optimal dose for
those with liver disease, its duration of action is pro- visceral analgesia seems to be 0.2 mg/kg. Its efficacy
longed, but it is still very safe. Cats are able to metabo- against somatic pain is very poor at doses from 0.2 to
lize pethidine normally by demethylation and it has a 0.8 mg/kg. It has a very short elimination half-life and
similar elimination half-life in dogs and cats (30–60 clinically appears to give only brief (30–40 minutes)
minutes). analgesia postoperatively, with a relatively high number
of ‘failures’. Its effectiveness as a sedative and anti-
Fentanyl tussive seem to be better than its analgesic potency
Fentanyl is a pure µ-agonist, 1000 times more potent (Waterman and Kalthum, 1992).
than morphine. It is not licensed in animals, except in
combination with fluanisone. It causes marked brady- Pentazocine
cardia and respiratory depression in high doses. It has Pentazocine is a benzomorphan derivative. It is a partial
a rapid onset of effect (1–2 minutes) and short duration µ-agonist, and κ-agonist with a potency 1/4 that of
of action (20–30 minutes). Its main value is as an morphine. It has a flat dose–response curve and a
intraoperative analgesic to control acute intense pain tendency to produce dysphoria. Analgesia is reasonable
and as a ‘rescue analgesic’ postoperatively if pain is postoperatively, with a duration of around 1–2 hours
proving difficult to control. although sedation lasts considerably longer (Waterman
and Kalthum, 1992). It has a short elimination half-life
Methadone in the dog, lasting slightly longer in the cat.
Methadone is a synthetic µ-agonist, equipotent with
morphine, but not licensed for use in animals. It pro- NSAIDs
duces less sedation than morphine, but has a long Most NSAIDs are potent inhibitors of prostaglandin
duration of action in dogs. production, so that gastrointestinal, hepatic and renal
toxic side effects are seen with high or prolonged
Oxymorphone dosing. Relative or absolute hypovolaemia (such as
Oxymorphone is a semi-synthetic µ-agonist with ap- often occurs under anaesthesia or perioperatively) and
proximately 10 times the potency of morphine. It is not renal disease cause renal prostaglandins to become
available in the UK or Europe, but is widely used in the active in maintaining normal renal haemodynamics.
USA. It is said to cause less nausea and vomiting than The use of any NSAID that affects the production of
morphine, but a greater degree of auditory hypersensi- prostaglandins is inadvisable in these circumstances.
tivity and bradycardia with a predilection to cause This potential problem precludes their pre-emptive use
tachypnoea, as it disrupts thermoregulation. Its dura- (with the exception of carprofen, which has a prosta-
tion of action is quoted as 2–4 hours. glandin sparing effect). The older drugs in this group
are not effective for severe pain, but the newer agents
Buprenorphine e.g. flunixin, ketoprofen and carprofen, can provide
Buprenorphine is an extremely potent analgesic with excellent relief of acute postoperative pain (Lascelles
30–100 times the potency of morphine, and it is highly et al., 1994a). Doses for use in the cat and dog are
lipophilic. It is a partial µ-agonist but also has antagon- shown in Figures 6.2 and 6.3 respectively.
istic actions. Thus, while low doses are analgesic, higher
doses may be less effective. It has a slow onset of action Acetylsalicylic acid (aspirin)
and is not equally effective against different types of Acetylsalicylic acid is the oldest NSAID, but it is very
pain. These pharmacological properties have clinical toxic and can cause gastric irritation, aplastic anaemia
implications. First, the dose must be chosen carefully and hepatoxicity. In cats, its half-life is so long (40
and, second, the slow onset of action means that the drug hours) that cumulation can occur. There are safer
must be administered up to 45 minutes before the compounds available for analgesia.
analgesic effect is required. If animals are allowed to
recover in pain before the drug is active then it is unlikely Phenylbutazone
to be successful. Because buprenorphine binds avidly to Phenylbutazone is also cumulative, especially in cats
the receptor, it is very difficult to displace, so if the drug (elimination half-life 18 hours), and there is a high
is not effective, alternative opioid analgesic agents incidence of gastrointestinal and renal toxic side ef-
cannot be used to top up analgesia, nor can conventional fects with its use.
antagonists reverse its actions. If severe respiratory
depression occurs, doxapram must be given. Flunixin meglumine
Flunixin is an extremely potent analgesic, but can
Butorphanol cause severe gastrointestinal and renal damage, espe-
In addition to being a partial µ-agonist, butorphanol is cially in animals with pre-existing hypovolaemia. It is
also a κ-agonist. Like buprenorphine, its effect reaches equipotent to morphine in providing postoperative
a plateau (or ceiling) as the dose increases. This is pain relief in dogs (Reid and Nolan, 1991), but it is not
Analgesia 65

safe to use preoperatively. It has a shorter half-life in cats although it provides good postoperative analgesia
the cat than the dog, but nevertheless should still be for around 18–24 hours (Slingsby and Waterman-
used with extreme caution. Pearson, unpublished data). It has also proved clini-
cally effective in the amelioration of the pain associated
Ketoprofen with severe stomatitis in cats. Its safety margin, how-
Ketoprofen is a powerful inhibitor of both cyclo- ever, is unclear in the cat and gastrointestinal side
oxygenase and lipo-oxygenase enzymes and also in- effects are most likely, which may make the therapeu-
hibits bradykinin. It is, therefore, a very effective tic margin rather narrow. It may also be useful for long-
anti-inflammatory agent and a good analgesic. It pro- term postoperative analgesia if the dog or cat is eating.
vides effective, long duration postoperative
analgesia in cats and dogs, but may only be safely used Carprofen
postoperatively because of its cyclo-oxygenase inhibi- Carprofen differs from other NSAIDs because, despite
tory properties. A recent study in cats (Slingsby and being a good anti-inflammatory and potent analgesic
Waterman-Pearson, 1998) has shown that it agent, it has relatively very little effect on prostaglan-
provides postoperative analgesia equal in efficacy and din production. It seems to be tolerated extremely well
of longer duration than pethidine or buprenorphine. in dogs and cats, with few side effects. The main
indication for carprofen is as an analgesic, and because
Meloxicam it can safely be given preoperatively, its efficacy in the
Meloxicam is marketed mainly for treating chronic immediate postoperative period is maximized. Its safety
skeletal pain in dogs. It is not licensed for use in and efficacy, which are comparable to pethidine and

Drug Suggested dose (mg/kg) Length of treatment Particular indications


Licensed
Tolfenamic acid 4.0 s.c. q24h Maximum of 2 injections Analgesia (unlicensed) and
4.0 orally q24h Maximum of 3 days adjunct to treatment of upper
respiratory tract infections
Febrile conditions
Not for cats with gastrointestinal,
renal or cardiac disease or
hypovolaemia
Ketoprofen 2.0 s.c. q24h Maximum of 3 days Analgesia and anti-inflammatory
1.0 orally q24h Maximum of 5 days Not for preoperative use
Not for cats with gastrointestinal,
renal or cardiac disease or
hypovolaemia
Carprofen 2.0–4.0 i.v., s.c. q18–24h Single dose As a perioperative analgesic
4.0 orally q24h Tablets for long-term Safe to use preoperatively
treatment of chronic pain
or inflammation
(unlicenced use in cats)
Unlicensed
Meloxicam 0.3 orally on day 1, Maximum 4 days Postoperative analgesia
followed by 0.1 orally Probably well tolerated Not for preoperative use
q24h long-term
Flunixin 1.0 s.c., i.v. or orally Single dose Postoperative analgesia
meglumine Not for preoperative use
Not for cats with gastrointestinal,
renal or cardiac disease or
hypovolaemia
Acetylsalicylic 10 orally q48–72h Anti-inflammatory
acid (aspirin) Analgesic
Prophylactic anti-thromboembolic
agent in cats with cardiac disease
Figure 6.2: Non-steroidal anti-inflammatory drugs for use in the cat.
66 Manual of Small Animal Anaesthesia and Analgesia

Drugs Suggested dose (mg/kg) Length of treatment Particular indications


Licensed
Tolfenamic acid 4.0 s.c. q24h Maximum of 2 injections Analgesia, not for preoperative
4.0 orally q24h Maximum of 3 days use
Anti-inflammatory
Gastrointestinal side effects as
for all NSAIDs
Ketoprofen 2.0 s.c., i.m. or i.v. q24h Maximum of 3 days Analgesia, not for preoperative
1.0 orally q24h Maximum of 5 days use
Anti-inflammatory
Contraindicated with
gastrointestinal, renal or cardiac
disease or hypovolaemia
(absolute or relative)
Carprofen 4.0 i.v., s.c. q18–24h Single dose As a perioperative analgesic
4.0 orally q24h Tablets for long-term Safe to use preoperatively
treatment of chronic pain
or inflammation
Meloxicam 0.2 s.c. Maximum 1 injection Postoperative analgesia
0.2 orally on day 1, Well tolerated long term For the relief of chronic pain,
followed by 0.1 orally e.g. osteoarthrosis on a
q24h ?long-term basis
Flunixin 1.0 s.c., slow i.v. or Maximum 1 injection Postoperative analgesia
meglumine orally Maximum 3 days orally Do not use preoperatively or in
dogs with gastrointestinal, renal
or cardiac disease or
hypovolaemia (absolute or
relative)
Do not use in dogs under 6
weeks of age or elderly animals
Dipyrone 1.0–2.5 ml i.v. or i.m. Analgesia
(in Buscopan Spasmolytic (for visceral pain
Compositum) especially)
Unlicensed
Acetylsalicylic 10–25 orally q24–48h Anti-inflammatory
acid (aspirin) Analgesic
Figure 6.3: Non-steroidal anti-inflammatory drugs (NSAIDs) for use in the dog.

morphine (but with a longer duration of action), make dration or liver, gastrointestinal or renal disease. It
it the most versatile drug to use as the basis for a seems to offer no advantage over other NSAIDs, and in
planned analgesic protocol for dogs and cats. Recent many respects it seems to be less safe. It is licensed for
work in the dog (Slingsby and Waterman-Pearson, use in dogs for the treatment of postoperative pain and
unpublished data) has shown that it use in combination in cats for the treatment of febrile conditions and upper
with pethidine produces enhanced analgesia compared respiratory disease. In a clinical trial of postoperative
with when either drug is used alone. analgesic efficacy in the cat, its duration of action was
It may be used orally to provide fairly long-term shorter than ketoprofen or carprofen (Slingsby and
postoperative pain relief, although cats sometimes find Waterman-Pearson, unpublished data).
the tablets unpalatable.
Etodolac
Tolfenamic acid Etodolac is an indole acetic acid derivative that is
Tolfenamic acid is chemically related to mefenamic approved in the USA for use in the dog as an analgesic,
acid. It has both analgesic and anti-inflammatory prop- anti-inflammatory and antipyrexic. It is said to inhibit
erties. It is not recommended for use in very young or cyclooxygenase-2 and therefore produce minimal ad-
very old animals or in those with any degree of dehy- verse effects on the gastrointestinal and renal systems.
Analgesia 67

However, occasionally it produces vomiting and re- Sevoflurane: This new volatile agent has also been
gurgitation. It is used to manage the pain of osteoarthritis shown to have some analgesic properties when used in
in the dog at a dose of 10–15 mg/kg orally and is given combination with intrathecal fentanyl.
once a day. Until it has been fully evaluated, the use of
etodolac should be accompanied by the restrictions
and cautions that apply to the other NSAIDs. ROUTES OF DRUG ADMINISTRATION
Miscellaneous drugs Most analgesics are given by the intramuscular, intra-
venous or subcutaneous routes to control acute post-
Alpha2-adrenoceptor agonists operative pain, or orally for more chronic pain. However,
Alpha2-adrenoceptor agonists (e.g. medetomidine, alternative routes can sometimes offer advantages.
xylazine) are analgesic, but they are not often used
solely for their analgesic action. If atipamezole is used Extradural approach
to reverse their effects, the analgesic effect is also Extradural analgesic drug administration is only logi-
reversed and, thus, pain relief is lost in the postopera- cal if the effects of the drug are more localized and
tive period. These drugs are dangerous if there is any more intense than when it is given systemically. The
degree of cardiovascular compromise. Very low doses advantage to using local anaesthetics by this route is
(0.1–0.2 mg/kg xylazine, 2 µg/kg medetomidine) may indisputable; whether there are such obvious benefits
be worth considering to control visceral pain or opioid- from using other analgesics in this way is less clear.
unresponsive pain in dogs with spinal cord damage. Drugs given by this route act directly on the spinal
cord by diffusing through the dura mater to neuronal
Ketamine tissue, and also via the dural cuffs. Systemic absorption
Ketamine, an NMDA antagonist, can play a part in may also occur, especially if drugs are highly lipophilic.
reducing postoperative pain. Since it acts on the NMDA
receptor it may both prevent and reverse the develop- Local anaesthetics
ment of CNS sensitization. It is a good analgesic against Local anaesthetics are routinely given extradurally and
ischaemic and somatic pain, although it has a relatively offer maximal block of sensory input. This technique
short duration of action. High doses provide longer is recommended for all major surgery of the hindlimb,
analgesia, but will induce dissociative anaesthesia. A perineal surgery and some abdominal surgery. Ligno-
dose of 1–2 mg/kg i.m. provides good analgesia in caine (1– 2%) or bupivacaine (0.25%) should be used
cats, and should certainly be considered for the initial at a rate of about 0.1–2 ml/kg or 0.5 ml/10 cm crown–
management of a difficult trauma case. rump length administered via the lumbosacral space.

Benzodiazepines Opioids
The involvement of benzodiazepines in the modulation Opioids may be administered extradurally to provide
of pain mechanisms remains controversial. Benzodiaze- analgesia in both dogs and cats. The advantage of
pines (diazepam or midazolam) enhance the inhibitory their use by this route is that analgesia is prolonged
actions of GABA by modulating GABAergic neurotrans- without motor impairment. Morphine has proved to
mission through the GABAA/benzodiazepine receptor be the most useful drug, but pethidine is also effec-
complex. Extradural and intrathecally administered tive. Highly lipophilic drugs such as fentanyl are far
midazolam produces postoperative analgesia after thor- less effective. Morphine is given at half the dose
acic and limb surgery in humans, but is less effective in recommended for systemic use, and made up to a total
alleviating visceral pain. Clinically, combinations of volume of 0.125 ml/kg for pelvic surgery, or 0.25 ml/
midazolam or diazepam with opiates are reported to kg for surgery of the abdomen. Onset of action is 20–
enhance opiate-mediated analgesia in humans. 60 minutes and given thus, it provides 16–24 hours’
analgesia. Side effects include pruritus, some respira-
Volatile and gaseous agents tory depression and urinary retention. These side
effects seem to be reversible with systemic adminis-
Methoxyflurane: This is an excellent analgesic at tration of naloxone, which does not seem to signifi-
subanaesthetic doses, which in the past made it an ideal cantly reverse the analgesia produced.
choice for orthopaedic surgery, where its slow elimi- Combinations of morphine and lidocaine can be
nation kinetics provided many hours of postoperative used for surgery, offering the advantage of an immedi-
analgesia. It is no longer available in the UK. ate sensory block with prolonged analgesia without
long-term motor impairment.
Nitrous oxide: This has good analgesic properties, but
these only persist for as long as it is administered. Its Alpha2-agonists
use, however, certainly helps reduce intraoperative Alpha2-agonists have been used extradurally in large
nociception. animals to provide long-term analgesia, but their cardio-
68 Manual of Small Animal Anaesthesia and Analgesia

vascular side effects are such that their routine use extra- FACTORS AFFECTING THE
durally cannot yet be recommended in cats or dogs. SEVERITY OF POSTSURGICAL PAIN
They may, however, have some potential in combina-
tion with opioids or local anaesthetics when much lower Patient considerations
doses can be employed, thus reducing their dangerous In general, young animals of all species have a more
side effects. limited repertoire of behavioural signs with which to
register their distress and so tend to exhibit similar overt
Ketamine and NSAIDs signs whether they are in pain, hot, cold or hungry. Older
Ketamine and NSAIDs have also been shown to be animals, however, seem to tolerate postoperative dis-
analgesic when given extradurally, but there are also comfort more stoically. Recent evidence from lambs
reports of neurotoxicity when they are given by this suggests that neonates have a lower pain threshold than
route (Pascoe, 1997). older animals (Thornton and Waterman-Pearson, un-
published data). Very young kittens and puppies have
Transdermal approach immature kidney and liver function, making the meta-
The transdermal approach provides a simple method of bolism and excretion of drugs limited compared with
continuous parenteral drug administration. To over- adults. They also become hypothermic very easily,
come the skin barrier to transdermal transport, drugs which further decreases the rate of elimination of drugs.
need to be of small molecular weight, lipophilic, Drugs that are generally rapidly metabolized, such as
uncharged and potent. Clinically, in animals, only fen- pethidine, should therefore be used, and the dosing
tanyl has been used in this way. Absorption is slow and intervals should be increased to prevent cumulation.
the fentanyl patches have to be applied 12–24 hours Elderly animals also need to be treated with care.
before surgery to provide background postoperative They are likely to be thin and have reduced hepatic and
pain relief. There are practical problems with maintain- renal reserves. These ageing changes will lead to a
ing patches in place in dogs, and there is tremendous smaller volume of distribution for drugs and a slower
variation in the plasma concentrations of fentanyl that rate of elimination. Again, drug doses and dosing
are achieved. While this technique may offer a back- intervals may need to be adjusted accordingly.
ground level of analgesia, rapid and reliable changes to Certain breeds seem to be more susceptible to pain,
the delivery rate are not possible and so it is not versatile or at least exhibit more overt signs. Notably the Grey-
enough to control acute peaks of postoperative pain, and hound family, some toy breeds and Staffordshire Bull
additional parenteral doses of other drugs are needed, Terriers often seem to suffer great distress after rela-
making the logic of their use questionable. tively minor surgery, whereas Labradors, for example,
The use of fentanyl patches to control chronic pain seem much more stoical.
may theoretically offer some advantages to repeated
injections or the prolonged use of NSAIDs. Side effects Surgery
include reduced appetite, respiratory depression and brady- A major factor influencing the severity of pain is the
cardia. Increases in body temperature can markedly nature of the surgical interference. The severity of tissue
enhance absorption, making overdosage possible. There damage, amount of inflammation, degree of tension
is, in addition, the risk of both deliberate and inadvertent and/or movement of surrounding muscles, strength of
human misuse of these patches, with potentially lethal contraction of smooth muscles or degree of distension of
results. It is difficult to envisage the widespread use of hollow organs all influence the severity of postoperative
this technique in veterinary practice in the UK. pain. In addition, if there is damage to, or pressure on,
Iontophoresis is an enhanced mode of transdermal nerves (which may be iatrogenic in origin, e.g. too tight
drug administration using an electrical current to ion- bandaging), or tissue ischaemia, postoperative discom-
ize drugs. The advantage of this over simple occlusive fort will be increased. It is axiomatic, therefore, that
patches is obvious; there will be rapid achievement of there should be no unnecessary disruption of tissues.
a steady state and an ability to vary the rate of drug Exposed tissues should be kept vital and covered in
administration, allowing far greater flexibility in the warm saline-soaked swabs. Tourniquets can cause in-
control of acute pain. tense noxious stimulation and marked hyperalgesia
within 20 minutes in conscious animals. If they are used
Intranasal approach under anaesthesia this should be borne in mind. Skin
Intranasal administration of opioids, using a metered sutures that are too tight can also cause intense irritation.
spray, may offer advantages in needle-shy animals or
ones where venous access is not possible. Butorphanol,
pethidine and fentanyl have all been used in this way in SPECIFIC RECOMMENDATIONS
humans; absorption is very rapid and bioavailability is
good. Metered doses of 10–25 µg/kg of fentanyl have Trauma
proved to be safe in lambs (Waterman-Pearson and Following trauma, dogs and cats may be difficult to
Thornton, unpublished data). handle, and provision of analgesia with a drug that has
Analgesia 69

some sedative properties can be beneficial. In order to should certainly be given the benefit of the doubt and
allow frequent re-evaluation of the case, a short-acting analgesia provided before, during and after surgery,
drug such as pethidine or butorphanol should be cho- utilizing potent opioids, NSAIDS and a local block
sen initially. Animals with head injuries need to be (extradural or brachial plexus block) if possible.
monitored very carefully, as any respiratory depres- Spinal surgery leads to marked discomfort
sion will lead to an increased PaCO2, cerebral vaso- postoperatively, the source of the pain being largely the
dilation and an increase in intracranial pressure. extensive muscle disruption caused, although haemor-
Fractious cats may be given low doses of ketamine in rhage around the spinal cord can also lead to an increase
combination with midazolam (see Chapter 7). in pressure on the cord and spinal nerves, which is
intensely painful. The severity of the pain with these
Ophthalmic surgery types of surgery makes the use of potent µ-opioids,
Ocular pain can be most distressing, and animals usually with an NSAID, mandatory. The addition of a
will attempt to rub and scratch their eyes if relief is not benzodiazepine in low doses may also prove beneficial.
provided. The mediation of the pain associated with Occasionally these patients suffer severe opioid-
intraocular surgery is such that it is best controlled unresponsive pain postoperatively, especially when
by a combination of topical local anaesthesia and there is spinal cord ischaemia. This pain often responds
an NSAID, although the sedative properties of pethidine to low doses of α2-agonists or ketamine.
can also be beneficial. Following ocular surgery, a rise
in intraocular pressure can be disastrous, and therefore Thoracic surgery
drugs that may cause retching or vomiting must be Thoracic surgery is very painful in humans, but in dogs
avoided; the administration of low doses of a sedative and cats there is less long-term discomfort once the
such as acepromazine postoperatively can also promote indwelling chest drain is removed. However, the im-
a quiet pain-free recovery (see Chapter 12). mediate postoperative period can be very distressing,
especially in small dogs and cats. The pain emanates
Aural surgery from disruption of the intercostal muscles and the
This can be very painful and if the animal starts to pleural pain associated with the presence of the chest
shake its head, a vicious circle of increasing pain drain. Impairment of respiration, caused by reluctance
provoking more head shaking can easily be set up. A to expand the thoracic cage, is not such a problem in
potent opioid, given as part of the premedication and dogs as it is in humans, although if there has been an
topped up postoperatively should provide good pain extensive repair to the diaphragm, ventilation can be
relief. In addition, a single dose of an NSAID such as impaired. Postoperative pain control should always
carprofen should be given at the start of surgery and, if include some form of regional block with a long-acting
possible, topical anaesthesia with EMLA cream should local anaesthetic agent infiltrated intercostally and/or
also be provided at this stage. intrapleurally, as well as administration of a balanced
combination of an opioid and an NSAID.
Dental extractions
In the case of dental extractions, opioids are not very Abdominal (visceral) surgery
effective. In these cases postoperative analgesia should In small animals, intra-abdominal manipulations cause
be provided by the use of an NSAID such as carprofen much less postoperative discomfort than in humans,
or ketoprofen. Mandibular and/or maxillary nerve probably due to the fact that quadrupeds do not have to
blocks may also be used (see Chapter 13). move their abdominal muscles as much while walking
or breathing. Cranial abdominal surgery is more pain-
Orthopaedic surgery ful because of the necessity to stretch the costal area
Orthopaedic procedures, especially those involving during manipulations. Perianal and rectal surgery is,
joints, or long bone fractures with over-riding of the likewise, painful, and dogs will often strain incessantly
fracture and muscle spasm, are extremely painful. The or be reluctant to defecate postoperatively.
source of the pain is difficult to localize, but muscle For most types of visceral surgery, pethidine rather
damage as much as periosteal disruption may be re- than morphine is preferred since it does not provoke
sponsible for any distress. The analgesic protocol vomiting, spasm of sphincters or urinary retention, and
should include a potent opioid (morphine) given its spasmolytic effect can be beneficial. Partial µ-/full
preoperatively, to provide cover during the surgery, κ-agonists such as butorphanol can also be effective.
which should then be topped up in the postoperative Both these drugs will require repeated administration
period for 12 hours or so. In addition, an NSAID should postoperatively.
also be administered perioperatively to give longer-
term pain relief (carprofen or ketoprofen). Other causes of postoperative pain
Limb amputation is extremely painful, although A distended bladder or a leg swollen by the extravasa-
there is no way of knowing whether animals, like tion of intravenous fluids can cause marked discomfort
humans, suffer from phantom limb pains. Animals and postoperative restlessness.
70 Manual of Small Animal Anaesthesia and Analgesia

Muscle spasms may provoke marked pain after trauma and the patient’s ability to cope. Experience
surgery, and some thought should be given to adding a suggests that pain is profound for at least 2–3 days and
drug with muscle relaxant properties into the analgesic so some form of analgesic treatment should be contin-
treatment regimen for cases where this may be a ued for at least 72 hours. Potent opioids may be
problem. Benzodiazepines are particularly useful here, discontinued after 24 hours, with NSAIDs becoming
as their mild sedative properties can be beneficial and the mainstay of treatment.
they also have some analgesic activity. Ideally, the drug chosen for longer-term pain relief
Wound care is also of great importance since infec- should be safe, orally active and palatable and should
tion increases inflammation causing increased pain. Good have a short latency and a long duration of action so that
toilet includes proper care of all intravenous or urinary it may be used tactically rather than on a continuous
catheters and any invasive monitoring equipment. basis. Clearly, at present there is no ideal drug available,
Finally, the animal’s mental state should not be although the new NSAIDs are far safer than older agents
neglected. Anxiety is a well recognized contributory and may be usefully employed as long as the animal is
factor to the severity of pain in humans and, although monitored carefully and re-evaluated frequently to mini-
animals do not worry about the risk of dying under mize the risk of serious side effects occurring.
anaesthesia, or the long-term prognosis, there is no doubt
that the experience of waking up in a strange place and
separation from the owner can cause anxiety and distress.
REFERENCES AND FURTHER
READING
NON-PHARMACOLOGICAL Bach S, Norveng MF and Tjjellden NU (1988) Phantom limb pain in
METHODS OF PAIN RELIEF amputees during the first twelve months following amputation
after preoperative lumbar epidural blockade. Pain 33, 297–230
Coderre TJ, Vaccarino AL and Melzack R (1990) Central nervous
All too often the only considerations in the manage- system plasticity in the tonic pain response to subcutaneous formalin
ment of pain relief or prevention are pharmacological injection. Brain Research 535, 155–158
Joel E and Arndts F (1925) Beitrage zur Pharmakologie der
measures. There are, however, sound nursing meas- Korperstellung der Labyrinth. XIX Mitteilungen. Morphin. Arch.
ures that can also have a major impact on reducing the Gesellschaft (Physiology) 210, 280
level of postoperative pain. Lascelles BDX, Butterworth SJ and Waterman AE (1994) Postoperative
analgesic and sedative effects of carprofen and pethidine in dogs.
The redeeming feature of acute postoperative pain Veterinary Record 134, 187–191
is that, by and large, its intensity declines quickly with Lascelles BDX, Cripps PJ, Mirchandani S and Waterman AE (1995)
Carprofen as an analgesic for post-operative pain in cats: dose
time and, if the patient can sleep, the pain diminishes. titration and assessment of efficacy in comparison to pethidine
The environment should therefore be quiet, and one hydrochloride. Journal of Small Animal Practice 36, 535–541
might even consider giving a low dose of a sedative to Lascelles BDX, Cripps PJ, Jones A and Waterman A (1997) Postoperative
central hypersensitivity and pain: the pre-emptive value of pethidine
encourage sleep if the patient is particularly agitated. for ovariohysterectomy. Pain 73, 461–471
Cats, in particular, appreciate a quiet environment Lascelles BDX and Waterman AE (1997) Analgesia in cats. In Practice
19, 203–213
postoperatively; a barking dog in the next cage is not Lascelles BDX, Waterman AE, Cripps PJ, Livingston A and Henderson
conducive to a stress-free recovery! G (1995) Central sensitization as a result of surgical pain –
Giving the animal some attention once every so investigation of the pre-emptive value of pethidine for
ovariohysterectomy in the rat. Pain 62, 201–212
often is of immeasurable benefit and helps decrease the Pascoe PJ (1997) Drugs in the epidural space. Proceedings of the 6th
distress associated with pain and the unfamiliar envi- International Congress of Veterinary Anaesthesia. pp. 53–62
Reid J and Nolan AM (1991) A comparison of the post-operative
ronment, otherwise a cycle of pain/distress/sleepless- analgesic and sedative effects of flunixin and papaveretum in the
ness can develop. dog. Journal of Small Animal Practice 32, 603–608
Slingsby LS and Waterman-Pearson AE (1998) A comparison of pethidine,
Animals benefit from the provision of a comfort- buprenorphine and ketoprofen for postoperative analgesia after
able bed in a warm, though not too hot, environment. ovariohysterectomy in the cat. Veterinary Record 143, 185–189
They should be offered food and water, if appropriate, Wall PD and Melzack R (1994) Textbook of Pain. Churchill Livingstone,
Edinburgh
fairly early in the postoperative period. Pain and in- Wall PD and Woolf CJ (1984) Journal of Physiology 356, 443–458
flammation cause an increase in basal metabolic re- Waterman AE (1988) Analgesia in the dog and cat. Advances in Small
Animal Practice 1, 159–181
quirements, and a high level of nutrition will be required Waterman, AE and Kalthum W (1992) The use of opioids in providing
to promote healing. Offering food early in the post- postoperative analgesia in the dog: a double blind trial of pethidine,
operative period not only speeds recovery, but can also pentazocine, buprenorphine and butorphanol. In: Animal Pain and its
Control (Proceedings of a Symposium, Cornell University July 1990),
have a soothing effect on a restless animal. ed. CE Short, pp 466–479. Churchill Livingstone Inc., New York
Woolf CJ (1983) Evidence for a central component of post injury pain
hypersensitivity. Nature (London) 306, 686–688
Woolf CJ and Chong M-S (1993) Pre-emptive analgesia treating post-
DURATION OF ANALGESIC operative pain by preventing the establishment of central
TREATMENT sensitisation. Anesthesia and Analgesia 77, 326–343
Woolf CJ and Wall PD (1986) Relative effectiveness of C primary
afferent fibres of different origins in evoking a prolonged
The length of time that treatment should be continued facilitation of the flexor reflex in the rat. Journal of Neuroscience
postoperatively is variable, depending on the degree of 6, 1433–1442
CHAPTER SEVEN

Premedication and Sedation


Victoria M. Lukasik

INTRODUCTION few years, but their use is still recommended in


combination with drugs anticipated to cause brady-
Preanaesthetic drugs are an important component of a cardia or increase salivation.
complete anaesthetic protocol. They help relieve anxi- Anticholinergics are contraindicated in patients
ety and decrease stress before induction of anaesthesia. with pre-existing tachycardia. This includes patients
They also increase patient and staff safety during with sinus tachycardia as well as patients with other
restraint and facilitate manipulations such as placing tachyarrhythmias.
intravenous catheters. Preanaesthetic drugs contribute
to a smooth induction and recovery from anaesthesia. Atropine sulphate
Specifically, premedication protocols should be de- Effective doses of atropine sulphate in dogs and cats
signed to: range from 0.02 to 0.04 mg/kg s.e. or i.m. and from
0.01 to 0.02 mg/kg i.v. When given intravenously,
Reduce anxiety and calm patients atropine may initially cause an increase in vagal tone
Produce mild to moderate sedation leading to bradycardia, which is followed by choliner-
Provide analgesia before surgery gie blockade and tachycardia. Atropine will cross the
Increase muscle relaxation blood-brain barrier and the placenta. Atropine over-
Decrease saliva and airway secretions dose leads to stimulation of the central nervous system
Reduce unwanted side effects of subsequent (CNS) and can precipitate seizures. Although contro-
anaesthetic drugs versial, severe cases of atropine overdose can be treated
Suppress vomiting and regurgitation with physostigmine 0.02 mg/kg i.v., given slowly to
Decrease the amount of drug needed to produce effect. Administration of physostigmine should prob-
unconsciousness ably be reserved for cases in which patients undergo
Contribute to analgesia postoperatively. seizures, experience extreme agitation or are at risk of
injuring themselves or others.
Surgical procedure, anaesthetic duration, anticipated Atropine relaxes the iris sphincter muscle, causing
complications, postoperative needs and patient age, the pupil to dilate. This effect is especially prominent
size, temperament and physical condition should ali be in cats. For this reason, atropine is contraindicated in
considered when choosing drugs for premedication. patients with narrow angle glaucoma and synechia.
Preanaesthetic protocols usually include combinations Atropine bas been shawn to decrease tear formation in
of anticholinergics, sedatives or tranquillizers, and dogs. It may be beneficiai to protect the patient's eyes
opioid analgesies. with sterile lubricant when atropine is included m
preanaesthetic protocols.
Other uses of atropine include:
ANTICHOLINERGICS
Treatment of sinus bradycardia, sinoatrial arrest
Anticholinergics are parasympathetic antagonist drugs and incomplete atrioventricular black
that are often included in premedication protocols to Antidote for overdose of cholinergie drugs like
decrease salivation and prevent bradycardia . These physostigmine
drugs also cause bronchodilation and a decrease in Antidote for organophosphate poisoning
gastrointestinal secretions and gastrointestinal motor Antidote for muscarinic mushroom poisoning
function. The administration of an anticholinergic Treatment of hypersialism
decreases the undesirable autonomie effects of Treatment of bronchoconstrictive disease.
drugs used to reverse neuromuscular blockade (e.g.
neostigmine, edrophonium, physostigmine). Routine Atropine is reportedly compatible when mixed in
use of anticholinergics has decreased over the past syringes and intravenous tubing with:
72 Manual of Small Animal Anaesthesia and Analgesia

Butorphanol Pethldine
Buprenorphine Morphine
Diphenhydramine Neostigmine
Droperidol Oxymorphone.
Fentanyl
Glycopyrrolate Glycopyrrolate is reportedly incompatible when mixed
Pethidine (meperidine) in syringes and intravenous tubing with:
Morpl1ine
Oxymorphone Dexamethasone
Pentazocine. Diazepam
Methohexitone
Atropine is reportedly incompatible when mixed in Methy lprednisol.one
syringes and intravenous tubing with: Pentazocine
Pentobarbitone
Noradrenaline Sodium bicarbonate
Methohexitone Thiopentone.
Sodium bicarbonate.
Antihistamines, benzodiazepines, pethidine, phenothia-
Antihistam ines, benzo dia ze pines, pethidin e, zines, procainami.de and quinidine may enhance the
phenothiazines, procainamide and quinidine may ali effects of glycopyrrolate. Long-tenn corticosteroid
enhance the activity of atropine. Long-term cortico- use can potentiate the adverseeffects of glycopyrrolate,
steroid use can potentiate the adverse effects of atro- and intraocular pressure may increase. Gl ycopyrrolate
pine, and intraocular pressure may increase. Atropine may enhance the effects of sympathomimetics and
may enhance the effects of sympathomimetics and may antagonize the effects of metoclopramide.
may antagonize the effects of metoclopramide.
TRANQUILLIZERS
Glycopyrrolate
Effective doses of glycopyrrolate in dogs and cats Tranquillizers and sedatives are used to calm patients
range from 0.01 to 0.02 mg/kg s .e. or i.m. and from and to improve the quality of anaesthesia induction and
0.005 to 0.01 mg/kg i.v. Vagal inhibition lasts 2 to 3 recovery. They also decrease the amount of induction
hours, and secretions may be decreased for as long as drug needed to produce unconsciousness. It is impor-
7 hours. Glycopyrrolate is a large polar quaternary tant to allow sufficient time for tranquillizers to take
ammonium molecule that does not readily diffuse full effect before anaesthesia induction otherwise a
across lipid membranes such as the blood-brain bar- relative overdose of induction and maintenance drugs
rier and placenta. Because of its quaternary structure, may occur. It is best to leave patients in a quiet area for
minimal effects on the CNS and fetus would be ex- 15 to 30 minutes while tranquillizers are taking effect.
pected after overdose with glycopyrrolate. Tranquillizers and sedatives commonly used in pre-
AtcJinjcally useful doses, glycopyrrolate is slightly medication protocols are th e phenothiazin es ,
Jess arrhythmogenic than atropine. The manufacturer benzodiazepines and butyrophenones.
ofthe veterinary product in the USA lists only mydria-
sis, tachycardia and xerostomia as adverse effects in Phenothiazines
dogs and cats when glycopyrrolate is used at recom- Acepromazine is the most commonly used phenothl-
mended doses. azine in veterinary medicine. Other phenothlazines used
Other uses of glycopyrrolate include: on rare occasions include chlorpromazine, promazine,
promethazine, trimeprazine and methotrimeprazine.
Treatment of bradyarrhythmias
Treatment of hypersialism Acepromazine maleate
As a bronchodilator. Although not consistent with manufacturers' recom-
mendations, effective doses of acepromazine in dogs
Glycopyrrolate is reportedly compatible when mixed and cats range from 0.02 to 0.075 mg/kg s .e. or i.m. to
in syringes and intravenous tubing with: a maximum dose of 3 mg, regardless of patient size.
Large and giant breed dogs are easily overdosed with
B uprenorphlne acepromazine, and the lower end of the dose range
Diphenhydramine should be used in these patients. The onset of action
Droperidol can be relatively slow, requiring 30 to 60 minutes
Droperidol and fentanyl before peak effects are seen. It is important to allow
Fentanyl sufficient time for acepromaz~ne to take full effect
Lignocaine (lidocaine) before giving anaesthetic induction drugs.
Premedication and Sedation 73

Desirable effects of acepromazine include tran- geriatrie patients, very low doses have been associated
quillization, sedation and decreased adrenaline-induced with prolonged drug effects . Low doses have also
ventricular arrhythmias. Acepromazine also has anti- resulted in prolonged recoveries in large and giant
em etic, antispasmodic and weak antihistaminic prop- breed dogs. Acepromazine should be used with cau-
e rti es . Some r esearch ers have r eporte d that tion in these patients.
acepromazine has anticonvulsant properties. How- Acepromazine has no analgesie effects, so patients
ever, conventional thinking in veterinary medicine should be treated with appropriate analgesies to con-
holds that acepromazine may lower the seizure thresh- trol pain.
old in epileptic patients and precipitate seizures. Acepromazine is reportedly compatible when mixed
Increasing the dose of acepromazine may not lead to in syringes and intravenous tubing with:
increased sedation, but the incidence of unwanted side-
effects increases. If desired levels of sedation do not Atropine
occur after acepromazine administration, it is better to Buprenorphine
add another type of tranquillizer in combination with Butorphanol
acepromazine than to increase the dose. The tranquilliz- Ketamine
ing effects of acepromazine may be overridden by Oxymorphone.
catecholamines, and acepromazine cannot always be
counted upon when used as a sole restraining drug. Both glycopyrrolate and diazepam are reported to
Undesirable effects of acepromazine include: be physica lly inco mpatible when mi xed with
acepromazine in syringes, but glycopyrrolate is com-
Alpha-adrenergic blockade - may cause monly combined with acepromazine immediately be-
adrenaline reversai fore administration, with no apparent adverse effects.
Hypotension- can be profound
Chlorpromazine
Hypotherrnia
Chlorpromazine is used mainly as an anti-emetic, but
Excessive vagal tone
may be used as a tranquillizer or, in combination with
Bradycardia
other drugs, as a premedicant. Chlorpromazine is simi-
Potentiation of organophosphate toxicity
lar to acepromazine with regard to pharrnacological
A decrease in packed cell volume - occurs
activity, but is Jess potent and has a longer duration of
within 30 minutes, and may be as great as 50%
effect. Effective doses in dogs and cats range from 0.05
Ventilatory depression.
to 1.1 mg/kg i.m., administered 60 to 90 minutes before
anaesthesia induction.
If profound hypotension occurs after acepromazine
administration, cardiovascular fonction should be
Promazine
supported by aggressive administration of intrave-
Promazine has pharmacological actions s imilar to
nou s fluid. Treatm e nt w ith vasopressors or acepromazine. Effective doses in dogs and cats range
catecholamines may be indicated if cardiovascular
from 2.2 to 4.4 mg/kg i.m.
compromise is severe . Adrenaline is contraindicated
in patients overdosed with acepromazine. In the pres- Promethazine
ence of cx,-adrenergic blockade, adrenaline adminis- Promethazine is more commonly used as an anti-
tration may lead to unopposed P2 -receptor activity . histamine thanas a tranquillizer.
This effect augments vasodilation, and hypotension
may become more severe. Trimeprazine
Noradrenaline, phenylephrine and ephedrine are Trimeprazine has antihistaminic, sedative, antitussive
better choices for treating acepromazine overdose and antipruritic qualities. It is rarely used in prem edi-
because their primary site of action is the cx,-receptor, cation combinations.
and they have minimal activity at P2 -receptors.
Dobutamine is mainly a p,-receptor agonist, and Methotrimeprazine
dopamine has cx ,-rece pto r, p,-receptor a nd The combination etorphinefmethotrimeprazine is
dopaminergic effects. Altho ugh either drug may be cornn1ercially available. Each millilitre contains 18 mg
appropriate for treating acepromazine overdose, their of methotrimeprazine and 0.074 mg of etorphine. This
short duration of effect requires that dopamine and combination produces neuroleptanalgesia and hyper-
dobutamine be administered by constant rate infusion. glycaemia in dogs; it is not recommended in cats . It can
Acepromazine is contraindicated in hypovolaemic be given intramuscularly or intravenously and pro-
patients and those in shock. Acepromazine should be vides deep sedation, hypnôsis and analgesia that may
used cautiously in patients with cardiac dysfunction, be adequate for some minimally invasive surgical
decreased cardiac reserve, hepatic dysfunction or gen- procedures. Analgesia lasts for 60 to 90 minutes. If
eral debilitation. Paediatric patients are quite suscepti- general anaesthesia is to follow administration of
ble to the hypotensive effects of acepromazine. In etorphinefmethotrimeprazine, very small doses of an-
74 Manual of Small Animal Anaesthesia and Analgesia

aesthetic drugs are needed to produce and maintain C linicat doses of diazepam have very little effect
unconsciousness. Caution must be exercised to avoid on the cardiac and respiratory systems. Hig h intra-
inadvertent anaesthetic overdose. veno us doses can slightly depress ventilatio n, blood
Adverse effects of etorphinefmethotrimeprazine press ure, left vent ric ular functio n and cardi ac
include bradycardia, hypotension and respiratory de- o utput. An increase in heart rate may occur after
pression that may be severe enough to cause cyanosis. diazepam adminis trati on. The toxicity of dia zepam
Supplemental oxygen, intravenous fluids and assisted is relatively low. In the event of diazepam overdose,
ventilation may be necessary in patients sedated with the benzodiazepine antagonist, flumazenil , s ho uld
etorphinefmethotrimeprazine. This dntg combinati on be administered. In additi on, cardio pulmonary func-
should not be used in geriatrie patients or in any patient tio n should be s upported by administration of intra-
that may have decreased o rga n reserve. veno us fluids, adequate ventilatio n and oxygen
Hu mans are extremely suscepti ble to the effects of supplementatio n.
etorphine, and the combined dm g s hould be handled Diazepam should be given slowly to decrease the
cautio usly. Steps should be taken to a void inadvertent incidence of veno us thrombosis, and it s hould not be
injectio n, absorption throug h breaks in the s kin or given intra-arterially. In addition, rapid intravenous
absorption a cross mucous membranes. Care must a Iso injection of di azepam may cause haemolysis and
be exercised when disposing of needles and syringes. cardiotoxicity secondary to the propylene glycol base.
Naloxone, o r a noth er opioid antagonist s uitable for use Diazepam has been implicated in causing congenital
in hu mans, s hould be readily available. Staff should be abnormalities in humans if given during the first tri-
familiar with emergency procedures and prepared to mester of pregnancy. T he veterinary significance of
administer a id if an emergency develops. titis effect is unclear, but caution sho uld be exerc ised if
contempla ting using diazepam in a patient during earl y
Benzodiazepines pregnancy. Diazepam is also used to relieve status
The benzodiazepines exert their effects by binding to epilepticus in dogs and cats .
a specifi e be nzodia zepine bind in g site o n th e Diazepam may adsorb to plastic and should not be
y-aminobutyric acid (G ABA) receptor. These drugs stored in plasti c syringes. It may also adsorb sig nifi-
act as anx iolytics, hypnotics and anticonvulsants, and cantly to plastic bags containing solutions for intra-
they produce muscle relaxation through their effects venous administrati on, and to in fus io n tubing .
on the CNS. Benzodiazepines have no analgesie act- Diazepam is reportedly not compatible when physi-
ivity. They decrease postoperati ve restlessness in cally mixed with any o ther drugs or solutions, but is
patients receiving adequate analgesie medication. As commonly mixed with ketamine immediate ly before
preanaesthetics, benzodiazepines are often used in administration. Do no t administer any solution 111
corn bi nation with opioid analgesies. More commonly, which a precipitate forms and does not clear.
benzodiazepines are used in combination with the
dissociative drugs ketamine and tiletamine to induce Midazolam
general anesthesia. Benzodiazepines he lp prevent Effective doses of midazo lam in dogs and cats range
hypertonus and enhance sedatio n when used with from 0.07 to 0.22 mg/kg i.m. or i.v. M idazo lam is
dissociati ve drugs. The benzodiazepines include di- water soluble and is suitable for both intravenous
azepam, midazolam and zolazepam. Zolazepam is and intramuscular administration. It is twice as
only commercially available in the USA and then only pa tent as di azepam. Midazolam is s upplied at pH 3.5.
in combinati on with tiletamine . After administratio n, when pH increases to above
4 .0 , th e chemica l config uration of midazolam
Diazepam changes and it becomes lipid soluble. Midazolam
Effecti ve doses of diazepam in dogs range from 0.1 to is rapidly and a lmost completely absorbed after
0.6 mg/kg i.v. and in cats from 0.05 to 0.4 mg/kg i.v. intramuscular adminis tration.
Diazepam is fonnulated in a propylene glycol base. Titis Midazolam has very little effect upon cardiovascu-
formulation is not water soluble which makes the uptake lar function, but may de press ventilation at high doses.
of diazepam after intramuscular or subcutaneous ad- Midazolam overdose may be treated by administration
ministration unpredictable and poor at best. Therefore, of flumazenil , supporting cardiovascular function and
diazepam should only be given intravenously. An emul- ensuring adeq uate ventilatio n.
sion of diazepam for injection is available in severa! Midazolam is reportedly compatible when mixed
countries. This preparation obviates sorne of the prob- in syringes and intravenous tubing with:
lems associated with propy lene glycol but may have
reduced bioavailability. Because diazepam decreases Atropine
inhibition, patients given only diazepam may actually Fentanyl
become more difficult to handle. Diazepam works weil Glycopyrrolate
in combination with opioid analgesies, increasing seda- Ketamine
tion and patient manageability. Morphine.
Premedication and Sedation 75

Zolazepam In addition to sterile water, zolazepam/tiletamine is


Zolazepam can be combined with the dissociative commonly reconstituted with xylazine or a combina-
drug tiletamine (see section on ketamine in sedation). tian of xylazine and ketamine, with no apparent physi-
In one preparation, zolazepam/tiletamine is supplied cal incompatibility. Solutions that are discoloured or
as a lyophilized powder in 5 ml vials. Each vial that contain a precipitate should not be used.
contains 250 mg of tiletamine hydrochloride and
250 mg of zolazepam hydrochloride. After reconsti - BENZODIAZEPINE ANTAGONIST
tution with 5 ml of sterile water, each millilitre of
solution contains 100 mg/ml of drug (50 mg of Flumazenil
tiletamine and 50 mg of zol azepam) . Doses for this The actions of the benzodiazepines can be effective!y
product are reported in mg/ kg of the combined prod- antagonized by the drug fi umazen i1. The effective dose
uct: the two drugs are considered one product for of flumazenil in dogs and cats is 0.1 mg/kg i.v.
dosing purposes . Effecti ve doses in dogs range from Flumazenil's duration of effect is short (about 60
6.6 to 9.9 mg/ kg i.m. or 2 to 4 mg/kg i.v., and in cats minutes). It may be necessary toredose with flumazenil
from 6 to 11.9 mg/ kg i.m. when large doses of benzodiazepine need to be re-
The drug combination provides sedation and versed. The effects of flumazenil are usually observed
analgesia that may be adequate fo r minor diagnostic after 2 to 5 minutes. Reversai is smooth, and patients
procedures. When combined with an opioid an- usually do not experience tachycardia, hypertension,
a lgesie it may allow minimally invasive s urgical anxiety or other signs of stress.
procedures. If the combination is used as a premedi- Flumazenil is compatible when mixed in the same
cation, the dose of subsequent anaesthetics may be syringe or intravenous tubing with:
greatly reduced.
Adverse effects include tachycardia, especially in Lactated Ringer' s solution
dogs, either hypertension or hypotension, respiratory 0.9 % saline solution
depression (common), apnoea, cyanosis and pul- 5 % dextrose in water.
monary oedema. Oxygen supplementation, assisted
ventilation and administration of intravenous fluids
ma y b e ne cessary in patie nts sed a ted with BUTYROPHENONES
zolazepam/tiletamine.
Athetoid movements (constant succession of Droperidol
slow, writhing, involuntary movements of flexion, Droperidol is available in combination with the opioid
extens ion, pronation, etc.) may occur; additional analgesie fentan yl citrate. Each millilitre of one prepa-
zolazepamftiletamine should not be given in an ration available in the USA contains 0.4 mg offenta-
attempt to diminish these movements. The eyes nyl citrate and 20 mg of droperidol. When this
usually remain open after heavy sedation with the combined drug is used for premedication, the effec-
drug combination and should be protected with a tive dose in dogs ranges from 0.05 to 0.1 ml/kg i.m.,
sterile eye lubricant. and in cats from 0. 1 to 0.11 ml/kg s.e. Maximal
Zolazepam/tiletamine is contraindicated in patients effects occur in 30 to 60 minutes. Caution must be
with pancreatic disease, severe cardiac disease or pul- exercised when using this product in cats because
monary disease. It crosses the placenta and may cause undesirable CNS stimulation may occur.
depression of the newborn . Patients given the drugs are In dogs, droperidolffentany l produces profound
predisposed to develop hypothermia, therefore an ex- analgesia of s hort duration (about 30 minutes)
ternat heat source should be provided. In addition, the and sedation, which lasts considerably longer. The
drugs will not abolish pinnal, palpebral, Iaryngeal or effects of droperidol/fentanyl may be s ufficient
pharyngeal reflexes. to allow minor procedures without the need for
Other undesirable effects include: additional anaesthetic drugs. Adverse cardiopul-
monary effects after administration of droperidolf
Emesis fentanyl include bradycardia, hypotension and res-
Excessive salivation - decreased by pre-eruptive piratory depression.
use of an anticholinergic Other effects that may be seen after administration
Excess tracheal and branchial secretions - of droperidolffentanyl are:
decreased by pre-eruptive use of an
anticholinergic Alpha-adrenergic block?de
Vocalization Panting
Erratic or prolonged recovery Aggressiveness up to 48 hours after recovery
Involuntary muscle twitching Defecation
Muscle rigidity (especially during recovery) Salivation
Pain at the injection site. Vomiting (rare) .
76 Manual of Small Animal Anaesthesia and Analgesia

Pretreating patients with an anticholinergic decreases consciousness does not occur unless excessive doses
or e liminates sorne undesirable side effects. Dogs are administered.
sedated with droperidoljfentanyl may be eas ily Butorphanol, morphine, oxymorphone, fentanyl,
aroused by auditory stimuli. Reversai of the analgesie buprenorphine and other potent opioids are usually
and sedative effects offentanyl can be accomplished combined with tranquillizers in premedication combi-
by administering naloxone hydrochl oride 0.04 nations . Opioids increase sedation and pro vide analge-
mg/kg i.v. The CNS effects of both droperidol and sia in the preoperative period and intraoperatively, and
fentany l can be antagonized with a combination of provide sorne postoperative analgesia.
naloxone 0.04 mg/kg mi xed with 4-aminopyridine
0.5 mg/kg, given intravenously. Morphine sulphate
Droperidoljfentanyl is reportedly compatible wh en Effective doses of morphine in dogs range from 0.1 to
till xed in syringes or intravenous tubing with: 2 mg/kg s.e., i.m. or very slowly i.v. Dogs generally
exhibit CNS depression after morphine administra-
Glycopyrrolate tion, but on rare occasions may become excited.
Pethidine. Morphine has central antitussive effects, may cause
pupillary constriction and can stimulate the chemo-
Fluanisone receptor trigger zone (CTZ) to cause votillting. Dogs
Fluanisone can be combined with fe ntanyl citrate. may become hypothertillc after morphine administra-
Each millilitre of one commercial preparation contains tion, therefore an external heat source should be
10 mg/ml fluanisone and 0.315 mg/ml of fentanyl available. Morphine can cause histatillne release from
citrate. This combined drug is no longer licensed for mast cells and should be administered very slowly if
use in dogs in the United Kingdom. Fluanisonejfenta- given intravenously. Morphine does not seem to ad-
nyl produces deep sedation and excellent analgesia sorb to plastic syringes, tubing or bags.
that may be adequate for minimally invasive surgical Morphine is considered a respiratory depressant;
procedures. Peak drug effects are observed in 15 min- dogs may pant heavily after its administration without
utes and analgesia lasts for about 30 minutes. The decreasing arterial carbon dioxide (PaC0 2 ) . It may
sedative effects of fl uanisone/fentanyl last consider- cause bronchoconstriction in dogs when given at mod-
ably longer than the analgesie effects. Fluanisone erate to high doses. Its cardiovascular effects in dogs
effectively prevents opioid induced vomiting. When range from bradycardia to tachycardia and include coro-
fluanisonejfentanyl is used as a preanaesthetic, the nary vasoconstriction, increased coronary vascular re-
amount of drug necessary to induce and maintain sistance and decreased systetillc arterial blood pressure.
general anaesthesia can be greatly reduced. Morphine decreases gastrointestinal motility and
Adverse effects of fluanisone/fentanyl include: secretions, but dogs often defecate immediately after
administration. Urination after morphine admi•listra-
Bradycardia - may be treated with an tion is also common, but bladder hypertonia may
anticholinergic occur, resulting in difficult urination.
Defecation Other uses of morphine sulphate in dogs include:
Responsiveness to auditory stimuli
Hypotension Analgesia
Respiratory depression. Treatment of hypermotile diarrhoea
As an antitussive
Fluanisonejfentanyl is contraindicated in patients with An adjunctive treatment of cardiogenic oedema
respiratory disease, renal disease or hepatic disease. An adjunctive treatment of supraventricular
The effects offentanyl can be effectively antagonized premature beats
with naloxone, but due to fentanyl 's short duration of Extradural analgesia - use preservative-free
effect reversai is usually lllmecessary. morphine.

Azaperone Effective doses of morphine in cats range from 0.05 to


Azaperone is indicated to control the aggressiveness of 0.1 mg/kg s.e. or i.m. Morphine should be used cau-
weanling and feeder pigs when pigs are mixed to- tiously in cats, because significant CNS stimulation
gether. It is not recommended for use in smali animais. can occur if it is used without a concurrent tranquil-
lizer. Cats can experience hyperthertilla after mor-
plline administration, and vomi ting may occur. Because
OPIOIDS the major route of morphine e limination is through
hepatic glucuronidation, its half-life may be prolonged
The pharmacology of the opioids is also described in in cats compared with dogs.
Chapter 6. Their analgesie effects may be accompa- Morphine is reportedly compatible when mixed in
nied by tillld sedation, but loss of proprioception or syringes or intravenous tubing with:
Premedication and Sedation 77

Atropine mild respiratory depression and bradycardia - the


Diphenhydramine latter may be reversed with atropine or glycopyrrolate.
Dobutamine Dogs may pant quite heavily after oxymorphone ad-
Droperidol ministration without decreasing PaC02 • Histamine
Fentanyl release rarely occurs, and there are minimal effects on
Glycopyrrolate cardiac output and arterial blood pressure. If used at
Metoclopramide. higher doses in cats, concurrent use of a tranquillizer is
recomrnended to avoid excitement.
Morphine is reportedly incompatible when mixed in O xymorphone is reportedly compatible when mixed
syringes or intravenous tubing with: in the same syringe or intravenous tubing with:

Aminophylline Acepromazine
Heparin sodium Atropine
Pentobarbitone Glycopyrrolate.
Phenobarbitone
Sodium bicarbonate Oxymorphone is reportedly incompatible when mixed
Thiopentone. in syringes or intravenous tubing with:

Pethidine hydrochloride (meperidine Barbiturates


hydrochloride) Diazepam.
Effective doses of pethidine in dogs range from 2
to 6.5 mg/kg s.e. or i.m and in cats from 2 to 4.4 Otheruses of oxymorphone hydrochloride in dogs and
mg/kg s.e. or i.m . Intravenous use is not recom- cats include:
mended. The dura ti on of effect in both dogs and cats
is o nly 1-2 hours. Analgesia
Pethidine is the only opioid used in veterinary medi- Sedation
cine that has vagolytic and negative inotropic properties Anaesthesia induction in geriatrie and s ick dogs
at clinically useful doses. Pethidine reduces salivation Intraoperative analgesia
and respiratory secretions and does not cause vomiting Extradural analgesia.
or defecation in most patients. It can cause histamine
release, particularly when given intravenously. Fentanyl citrate
Pethidine is reportedly compatible when mixed in Fentanyl is available alone or combined with either
the same syringe or intravenous tubing with: droperidol or fluanisone. When fentanyl is used in
preanaesthetic combinations, effective doses in dogs
Atropine range from O.Ql to 0.02 mg/ kg s.e., i.m. or i.v. (see
Diphenhydramine doses used for ana lgesia in Chapter 6) . Fentanyl has a
Dobutamine short duration of effect, about 20 to 30 minutes. Fenta-
Droperidol nyl may cause profound excitement in cats and is not
Fentanyl recommended for use without the concurrent adminis-
Glycopyrrolate tration of a tranquillizer.
Metoclopramide Fentanyl has little effect upon cardiac output and
Xylazine. blood pressure at clinically useful doses. Histamine
release rarely occurs. Intravenous and intramuscular
Pethidine is reportedly incompatible when mixed in administration may cause bradycardia that is easily
the same syringe or intravenous tubing with: reversed with atropine or glycopyrrolate. Fentanyl
usually does not induce vomiting in dogs, but defeca-
Aminophylline tion frequently occurs.
Heparin sodium Fentanyl is reportedly compatible when mixed in
Hydrocortisone the same syringe or intravenous tubing with:
Methylprednisolone
Pentobarbitone 5% dextrose in water
Phenobarbitone Lactated Ringer 's solution
Thiopentone. 0.9% saline
Glycopyrrolate
Oxymorphone hydrochloride Heparin
Effective doses of oxymorphone in dogs range from Hydrocortisone
0.05 to 0.2 mg/kg s.e., i.m. or i.v., and in cats from 0.05 Potassium chloride
to 0.4 mg/kg s.e., i.m. or i. v. Oxymorphone may cause Sodium bicarbonate.
78 Manual of Small Animal Anaesthesia and Analgesia

Other uses of fentanyl in dogs include: Pentobarbitone.

Analgesia - by constant rate infusion, Other uses of butorphanol in dogs include:


transdermal patch or multiple injections
intravenously As an antitussive - excellent for this purpose
Anaesthetic induction in sick dogs - often in Analgesia - for acute pain of Jess than 24 to 48
combination with a benzodiazepine. hours' duration
As an anti-emetic before cisplatin treatment.
Etorphine hydrochloride
Etorphine is an opioid agonist that is up to 1000 times Buprenorphine hydrochloride
more potent than morphine. It is available in combi- Effective doses of buprenorphine in dogs range from
nation w ith the phenothiazide tranquillizer 0.01 to 0.02 mg/ kg s.e., i.m. or i.v., and in cats from
methotrimeprazine. In this commercial preparation 0.005 to 0.02 mg/kg s.e. or i.m. Onset of action is
each millilitre contains 0.074 mg of etorphine and 18 relative!y slow, requiring 20 to 30 minutes, but analge-
mg of methotrimeprazine. This drug combination pro- sia may last 8 to 12 hours. Excitement may be seen in
duces neuroleptanalgesia and hyperglycaemia in dogs. cats ifbuprenorphine is given alone, therefore concur-
Bradycardia and hypotension may occur after etorphine rent administration of a tranquillizer is recommended.
administration. Etorphine is not recommended for use Like butorphanol, this drug partially reverses exo-
in cats (see section on methotrimeprazine above). genous and endogenous opioid agonists, and dimin-
Etorphine is extremely potent and great caution ishes the analgesia afforded by these compounds. For
must be exercised when handling this drug. If acciden- this reason buprenorphine should be used cautious ly in
tai self-administration occurs, death may result if a animais with moderate to severe pain that has been
reversai drug is not given immediately. Either nalor- present for more than 24 to 48 hours . Buprenorphine
phine or diprenorphine is recommended to reverse has little effect on cardiovascular function. Occasion-
etorphine in emergency situations. a lly, res pira tor y depression may occur after
buprenorphine administration.
Butorphanol tartrate Buprenorphine is reportedly compatible when
Butorphanol is a synthetic opioid that has both agonist mixed in syringes or intravenous tubing with:
and antagonist properties. Butorphanol will partially
reverse exogenous and endogenous opioid agonists and Acepromazine
will diminish the analgesia afforded by these com- Atropine
pounds. For this reason, this drug should be used cau- Diphenhydramine hydrochloride
tiously in animais with modera te to severe pain that has Droperidol
been present for more than 24 to 48 hours. Effective Glycopyrrolate
doses indogs rangefrom0.2 to0.8 mg/kg s.c.,i.m. ori. v, Xylazine.
and in cats from 0.2 to 0.4 mg/kg s.e., i.m. or i.v.
The respiratory depressant effects of butorphanol Buprenorphine is reportedly incompatible when mixed
are Jess than those of morphine and seem to reach a in syringes or intravenous tubing with:
ceiling effect beyond which higher doses do not in-
crease depression. Slight decreases in heart rate and Diazepam.
blood pressure can occur after butorphanol administra-
Other uses of buprenorphine include:
tion. However, butorphanol does not seem to cause
histamine release. Butorphanol has excellent sedative Analgesia - for acute pain of less than 24 to 48
properties in dogs, but on rare occasions can produce hours' duration
excitement when used alone. At higher doses, Extradural analgesia.
butorphanol may cause excitement in cats if a tranquil-
lizer is not also given. Pentazocine lactate
Butorphanol is reportedly compatible when mixed Pentazocine has poor sedative effects compared with
in the same syringe or intravenous tubing with: other opioids and is not usually used as a premedicant.
Pentazocine can cause dysphoria in cats and is possibly
Acepromazine best avoided in this species. Effective doses in dogs
Atropine range from 0.2 to 3.3 mg/kg i.m.
Diphenhydramine Undesirable effects associated with pentazocine
Droperidol include:
Xylazine.
Increased salivation
Butorphanol is reportedly incompatible when mixed in Respiratory depression
the same syringe or intravenous tubing with: Hypotension
Premedication and Sedation 79

Decreased gastrointestinal motility diprenorphine to reverse the effects of combined


Fine muscle tremor etorphi ne hydroch lo ride a nd methotrime prazine
Emesis ma y still experience moderate sedation due to the
Swelling at the injection site. lingering effects of methotrimeprazine. Dogs may
rena rcotize after 4 to 8 hours, and redosing of
Pentazocine is reportedly compatible when mixed in diprenorphine may be necessary. Diprenorphine has
syringes or intravenous tubing with: some opioid agonistic properties; overdosing may
pralong immobilization.
Atropine
Diphenh ydramine
Droperidol ALPHA2 -ADRENERGIC AGONISTS
Metoclopramide.
Alpha2 -adrenoceptors are prej unctional inhibitory
Pentazocine is reportedly incompatible when mi xed in receptors within the sympathetic nervous system
syringes or intravenous tubing with: and are found in the CNS, gastrointestinal tract,
uterus and kidney and on platelets. A lpha 2-agonists
Aminophylline produce analgesia, sedation, muscle relaxation and
Flunixin meglumine anxiolysis. When used as premedicants, they reduce
Glycopyrrolate the dose of subsequent intravenous and inhalant
Pentobarbitone anaesthetics by as much as 50%. Specia l attention
Phenobarbitone is required to prevent inadvertent overdose. The
Sodium bicarbonate. anaesthetic sparing effect is somewhat dose depend-
ent, but patients that seem poorly sedated stiJl requ ire
red uced doses of s ubsequent anaesthetic drugs .
OPIOID ANTAGONISTS The uptake of in halant anaesthetics may be delayed
after administration of cx2 -agonists, therefore more
The opioid antagonists have no ana lgesie acti vity. ti me may be necessary to induce general anaesthesia
They will effectively reverse a li pharmacologica l by mas k.
effects of opioid agonis t and agon ist-antagonist A lpha 2-agonis ts may ca use bradycard ia and
drugs. This includes the reversai of ali ana lgesie decrease cardiac output. Atropine and glycopyrrolate
effects. If a patient becomes severe!y depressed after are more effective at preventing bradycardia if
the administration of an opioid agonist, partial re- given befo re rxz-agonists than at reversing brady-
versa i with an opioid agonist-antagonis t would be cardia after it develops. Therefore, the pre-emptive
more appropriate if analgesia was still desired. adminis tration of an anticholi nergic drug may be
recommende d when us ing cx 2-agonists for pre-
Naloxone hydrochloride medication or sedation, a ltho ugh this re ma ins
Effecti ve doses of naloxone range from 0.04 to 0.1 controversial (see be low).
mg/kg i.m. or i.v. in both dogs and cats. Its duration Hypotension, which can be severe, is often seen after
of effect is abo ut 30 to 60 mi nutes. If reversai of a short period of increased blood pressure that immedi-
etorphine is necessary, naloxone can be used at a ately follows drug administration. Supporting cardio-
dose of 0.6 to 0.8 mg/kg i.v., butthe duration of effect vasc ul ar fun cti o n w it h intrave nous f luids is
is extreme ly s hort and renarcotization may occtu· in recommended when using rxz-agonists. Aftertheadmin-
10 to 15 minutes. istration of these drugs, peripheral veins may be difficult
to vis ualize. Placing intravenous catheters before seda-
Nalorphine hydrochloride tion is Jess difficult and allows for easy administration of
Nalorphine has a longer duration of effect than subsequent intravenous drugs and fluids.
naloxone. When used to reverse etorphine, nalor- After administration of cx2 -agonists, ventilation
phin e is dosed at the vo lum e:vo lum e ra tio may become shallow and intermittent. Some patients
na lorphine:etorphine of 1:10 to 1:20 given s lowly become cyan otic. Pulmonary oedema has a lso
intravenous ly . After intravenous injection, reversai been associated with the use of rxz-agonists. In addi-
ta kes place in about 3 minutes. Nalorphine has some tion, because hypothermia is common in patients
opioid agonistic properties; overdosing may pra long sedated with cx2 -agottists, an externat heat source
immobi lization. should be available.
Other side effects inc lude vomiting, especially in
Diprenorphine cats, slight muscle tremor, reduced intestinal motility
Diprenorphine effective ly reverses the effects of and increased uterine tone. Alpha2-agonists inhibit
etorphine. In ali species, diprenorphine is dosed ins ulin release resulting in hyperglycaemia, and de-
at 0.272 mg/ kg i.v. by slow injection. Dogs given crease antidiuretic hormone causing marked diuresis.
80 Manual of Small Animal Anaesthesia and Analgesia

Xylazine hydrochloride The manufacturers wam against using xylazine in


Xylazine is a mixed <XJa 1-agonist with an ~: a 1 selec- conjunction with other patent tranquillizers. Xylazine
tivity ratio of 160:1. It was first synthesized in the is commonly used with opioid analgesies in patients
1960s as an antihypertensive, but was found to have that will be given an ~-antagon istat the conclusion of
patent sedative effects in animais . Effective doses in a procedure.
dogs and cats range from 0.2 to 1.1 mg/kg s.e., i.m. or Xylazine is reportedly compatible when mixed in
i.v. The concentration of the product should bechecked syringes or intravenous tubing with:
before drawing xylazine into a syringe. The onset of
action after s ubcutaneous or intramuscular administra- Buprenorphine
tion is approximate ly 10 to 15 minutes, and after Butorphanol
intravenous administration is 3 to 5 minutes. Analgesie Ketamine
effects last for about 15 to 30 minutes, and sedation Pethidine
may persist for 1 to 2 hours. Without reversai with an Severa! other compounds (do not administer any
~-a ntagonist, complete recovery after xylazine ad- solution in which a precipitate has formed).
ministration may take 2 to 4 hours .
Xylazineshould be used cautiously in patients with Other uses of xylazine include:
pre-existing cardiac disease and th ose with ventricular
arrhythmias, hypotension, shock, respiratory dysfunc- Sedation
tion, hepatic or renal insufficiency and pre-existing As an emetic in cats
seizure disorder, or if debi litated. Because the ~­ Extradural analgesia.
agonists may increase uterine tone, xylazine should
not be used, or used with extreme caution, during Detomidine hydrochloride
pregnancy. Xylazine depresses thermoregulatory Compared with xylazine, detomidine hydrochloride
mechanisms, and either hypothermia or hyperthermia has a higher specificity for ~-receptors with an ~:a 1
may occur depending upon ambient temperature. This selectivity ratio of 260: 1. Detomidine acti va tes
effect may last beyond the sedati ve and analgesie a 1-receptors at higherdoses. Detomidine is more potent
effects of xylazine. Patients may be aroused by sharp than xylazine and was developed as a tranquillizer for
auditory stimuli, and fractious patients may not be use in horses and cattle. Effective doses in dogs range
adequate ly sedated with xylazine alone. Increasing the from 0.005 to 0.02 mg/kg i.m. or i. v., but its use is not
dose of xylazine does not generally increase the leve! recommended in small animais.
of sedation but pro longs the du ration of effect. L ike other aragonists, detomidine is contra-
Its effects upon the cardiovascular system include indicated in patients with cardiac arrhythmias, coro-
an initial increase in total peripheral resistance with nary insufficiency, cerebrovascular disease, res pira-
increased blood pressure followed by a longer period tory disease, hepatic disease or renal disease.
of hypotension. Bradycardia may be seen and sorne Detomidine s hould be used with extreme caution
patients develop second degree heart black. Cardiac in patients with traumatic or endotoxic shock, hypo-
output may be decreased upto 30 %. Xylazine has been te ns ion or de hydrati on, and those s tressed by
s hown to potentiate the arrhythmogenic effects of temperature extremes, fa tigue or high altitude. The
adrenaline. Respiratory fu nction is usually not af- manufacturer wam s against using detomidine with
fected with clinicall y usefu l doses of xylazine, but intravenous potentiated sulphonamide antibi otics
brachycephalic dogs may develop dyspnoea. Pulmo- because fata l arrhythm ias may develop.
nary oedema has been reported after xylazine admin-
istration in some species. Medetomidine hydrochloride
Decreased gastro-oesophageal sphincter pressure Medetomidine is the newest a 2 -agonis t approved
has been reported in dogs after xylazine administra- for veterina ry use. It is more patent and more
tion and may increase the likelihood of gastric reflux. effecti ve than other drugs in this c lass. Medetom idine
Emesis may be induced in cats and to a lesser degree is highl y selecti ve for the a 2 -adrenoceptor, having
in dogs. Vomiting is us ua lly seen within 3 to 5 an ~ : a 1 selecti vity binding ratio of 1620 :1. Effec-
minutes after administration. To prevent aspiration, tive doses in dogs range from 0.01 to 0.04 mg/kg
further anaesthetics s hould not be given unti l this s.e., i.m. or i.v. and in cats from 0.04 to 0.08 mg/kg
time period has la psed. Xylazine a lso prolongs s.e., i.m . or i.v.
gastrointestina l transittime in dogs. Acute abdominal H igher doses do not res ult in deeper sedation,
distension may occur in large dogs (bodyweight but pra long the duration of effect. Subcutaneous
~25 kg). This may be caused by aerophagia or by administration produces less re liable effects than
pa rasym patho lytic gastro intestin a l atony with intramuscular or intravenous administration. Frac-
accumulation of gas. Sedation with xylazine may tious or excited patients may not become sedated
not be appropriate fo r upper gastrointestina l radio- after the administration of medetomidine. Addition
graphy in large breed dogs. of an opioid or benzodiazepine in combination
Premedication and Sedation 81

with medetomidine enhances sedation and analgesia Atipamezole hydrochloride


beyond any effects achieved with medetomidine At ipamezole is indicated for the reversa i of
atone. If adequate sedation is not obtained, repeat medetomidine. Effective doses in dogs and cats
dosing is not recommended. range from 0.04 to 0.5 mg/kg i.m. Intravenous
Bradycardia is common after medetomidine ad- administration of atipamezole is not recommended.
ministration. The pre-emptive use of an anticholiner- Atipamezole will reverse sedation and analgesia
gic is more effective at preventing bradycardia than within 5 to 10 minutes of administration. Appropria te
reversing it, ifitdevelops. Atropine and glycopyrrolate analgesia should be provided for patients that
can inc rease the initial hypertens ive effects of require pain relief. Vomiting, hypersalivation, diar-
medetomidine. Anticholinergic plus medetomidine rhoea, tremors and excitement may occur after
combinations should be used with caution in patients atipamezole administration.
that may not tolera te hypertension. When medetomidine
is adm inistered with ketamine 5 mg/kg i.m. in cats, the
sympathomimetic properties of ketamine offset the NON-PROPRIETARY
bradycardie effects of medetomidine. PREANAESTHETIC COMBINATIONS
After medetomidine administration, there is an
initial increase in total peripheral resistance and blood Many drug combinations ha ve been used to pre-
pressure followed by a longer period of hypotension. medicate dogs and cats. The fo llowing combina-
Respiratory depression may occur; sorne patients be- tians are those with which the author has persona!
come cyanotic and require supplemental oxygen. experience, and the list is not comprehensive. Wh en
Hypothermia may occur in some patients, and an c hoosing drug combinations, the surgical proce-
externat heat source should be available. dure, anaesthetic duration, anticipated complica-
Othe r undesirable effects re ported after tions, adverse drug effects, postoperati ve needs and
medetomidine include: patient age, size, temperament and physical condi-
tion should ali be considered. The following protocols
Vomiting are designed to serve as examples, and doses should
Muscle twitching be adjusted to meet individua l patient needs.
Second degree heart block W hen drawing multiple drugs into the same
Diuresis syringe care must be exercised not to contaminate
Hyperg lycaemia vials. The order of drugs listed in the following
Excitement combinations is the recommended order for drawing
Prolonged sedation drugs into syringes. If anticholinergics are mixed
Circulatory failure (this occurs with two times with other drugs, the anticholinergic should be
the recommended dose or higher). drawn into the syri nge firs t. If anticholinergics are
lused pre-em ptively, intramuscular administration
The manufacturer wams against using medetomidine 5 minutes before the other drugs are admi nistered
in patients that are exercise intolerant, have cardiac is most beneficiai.
disease, respira tory disorders, hepati c disease or rena l
disease or are in shock. Medetomidine should not be Phenothiazine combinations
used in debil itated patients or those stressed due to These corn bi nations are genera li y used in young healthy
heat, cold, fatigue or altitude. active patients with enough organ reserve to withstand
the hypotensive and other adverse effects of
phenothiazines. Unless otherwise noted, corn binations
ALPHA-2 ANTAGONISTS listed may be appropriate fo r both dogs and cats. The
addition of glycopyrrolate O.Olmg/kg s.e., i.m. or i.v.
Yohimbine hydrochloride or of atropine 0.04 mg/kg s.e. or i.m. or 0.01 mg/kg i.v.
Yohimbine is indicated for the reversai of xy lazine to any of the following protocols may be appropriate in
in dogs and cats. Effective doses in dogs range sorne patients.
from 0. 1 to 0. 11 mg/kg i.v. and the dose in cats is
0.1 mg/kg i.v. Yohimbine may cause transient appre- Butorphanol and acepromazine
hension, CNS excitement, muscle tremors, sa li va- Butorphanol 0.4 mg/ kg and acepromazine 0.05 mg/kg
tion, increased resp iratory rate a nd hyperaemi c mixed in the same syringe and administered s ubcuta-
mucous membranes. Yohimbine will reverse any neously or intramuscularly.
analgesia afforded by xylazine and is contraindicated
in patients that are dependent upon cx 2-agonists Oxymorphone and acepromazine
for analgesia. Yohimbine should be used cautiously Oxymorphone 0.05 mg/kg and acepromazine 0.03
in patients with seizure disorders and renal dys- mg/kg mixed in the same syringe and administered
function. subcutaneously or intramuscularly.
82 Manual of Small Animal Anaesthesia and Analgesia

Morphine and acepromazine (dogs only) Alpha,-agonist combinations


Morphine 0.8 mg/kg and acepromazine 0.05 mg/kg CombirÏations th at include a 2 -agonist drugs are gener-
mixed in the same syringe and administered subcuta- a lly used in healthy exercise-tolerant patients. The pre-
neously or intramuscularl y. emptive use of glycopyrrolate 0.01 mg/kg i.m. or
atropine 0.04 mg/kg i.m . administered 5 minutes be-
Buprenorphine and acepromazine fore any of the following protocols may be appropria te
Buprenorphine 0.01 mg/kg and acepromazine 0.05 in some patients.
mg/kg mixed in the same syringe and administered
intram uscularly. But01·phanol and xylazine or butorphanol and
medetomidine
Benzodiazepine combinations B utorphanol 0.4 mg/kg and xylazine 0.3 mg/kg
These combinations are genera li y used in paediatric mixed in the same syringe and admi nistered
and geriatrie patients. They are also appropriate intramuscularly.
choices in patients with physiological compromise Butorphanol 0.4 mg/kg and medetomidine 0.04
or decreased o rgan reserve. Th e add ition of mg/kg mi xed in the same syringe and
glycopyrrolate 0 .01 mg/kg s.e., i.m. or i.v., or atro- administered intramuscularly.
pine 0.04 mg/kg s.e. or i.m. or 0.01 mg/kg i.v. to any
of the following protocols may be appropriate in Midazolam and xylazine or midazolam and
sorne patients. medetomidine
• Midazolam 0.1 mg/kg and xylazine 0.3 mg/kg
Butorphanol and midazolam or butorphanol and mixed in the same syringe and administered
diazepam intramuscularly.
• Butorphanol 0.3 mg/kg and midazolam 0.1 Midazolam 0.1 mg/kg and medetomidine 0.04
mg/kg mixed in the same syringe and mg/kg mixed in the same syringe and
administered intramuscularly. administered intramuscularly.
• Butorphanol 0.3 mg/kg i.m. followed 10 to 15
minutes later by diazepam 0. 15 mg/kg i.v. Medetomidine and ketamine (cats only)
Butorphanol 0.2 mg/kg slowly i.v. followed by Medetomidine 0 .05 mg/kg and ketamine 4 mg/kg mixed
diazepam 0.15 mg/kg i.v. in the same syringe and administered intramuscularly.

Fentanyl and midazolam (dogs only) ot· fentanyl


and diazepam (dogs only) SEDATION FOR MINOR PROCEDURES,
Fentanyl 0.01 mg/kg slowly i.v. followed by DIAGNOSTICS AND RADIOLOGY
midazolam 0.1 mg/kg i.v.
Fentanyl 0.01 mg/kg slowly i.v. followed by Physical restraint of veterinary patients is accompa-
diazepam 0.15 mg/kg i. v. nied by varying degrees of stress. Some calm patients
that do not resist handling cao be physically restrained
Buprenorphine and midazolam o•· with minimal risk of injury to staff or patient. How-
buprenorphine and diazepam ever, most patients benefit from some type of chemical
Buprenorphine 0.01 mg/kg and midazolam 0.1 restraint for procedures that require exact positioning
mg/kg mixed in the same syringe and or that are invasive. Drugs, or drug combinations, that
administered subcutaneously, intramuscularly or calm patients and provide analgesia decrease strug-
intravenously. gling and discomfort during diagnostic and minor
• Buprenorphine 0.01 mg/kg i.m. followed 20 to therapeutic procedures. Procedures can be carried out
30 minutes later by diazepam 0.15 mg/kg i.v. in less ti me and with grea ter precision wh en performed
Buprenorphine 0.01 mg/kg slowly i.v. followed on cooperative patients. Therefore, it is an advantage
by diazepam 0.15 mg/kg i.v. to both the veterinary surgeon and the patient to pro-
vide sedation and analgesia for most diagnostic and
Oxymorphone and midazolam or oxymorphone therapeutic procedures.
and diazepam Chemical restraint for diagnostic procedures and
Oxymorphone 0.05 mg/kg and midazolam 0. 1 minimally invasive surgery can be accomplished with
mg/kg mixed in the same syringe and sedation or general anaesthesia. In sorne cases, seda-
administered subcutaneously, intramuscularly or tion may be preferred to general anaesthesia. In other
intravenously. cases, a weil controlled genera l anaesthetic may be
• Oxymorphone 0.05 mg/kg i.m. followed 10 to 15 more beneficiai than heavy sedation. If minor surgery
minutes later by diazepam 0.15 mg/kg i.v. is planned, the use of local anaesthetic techniques in
Oxymorphone 0.03 mg/kg slowly i.v. followed addition to sedation will make patients more comfort-
by diazepam 0.15 mg/kg i.v. able and facilitate the procedure.
Premedication and Sedation 83

Combining two or more drugs from different classes Some seemingly innocuous diagnostic procedures
often potentiates desired drug effects and minimizes can precipitate pain, such as radiography of the hi p. A
unwanted side effects. Individual drug doses can be patient with severe coxofemoral arthritis may be in
reduced and patients still exhibit appropriate sedation pain on recovery due to positioning and manipulation
and analgesia. Balanced drug combinations are pre- du ring radiography. It is appropriate to pro vide analge-
ferred to large doses of a single drug. Whenever potent sia during and after procedures that may aggravate
sedative or analgesie drugs are used, patients must be existing conditions or cause pain. Oral analgesies,
carefully monitored and supported. Equipment for such as non-steroidal anti-inflammatory drugs
resuscitation should be available. (NSAIDs), can be prescribed for patients after release
The administration of intravenous tluids to ail from the veterinary hospital. Potential side effects of
patients th at are heavily sedated is appropria te, even if these drugs should be discussed with clients. It is
they are apparently healthy. Intravenous fluid support genera Ily assumed that any procedure that causes pain
is recommended in all cases when geriatrie and paedi- in humans will cause pain in animais. It is considered
atric patients are heavily sedated as well as in those unethical to withhold analgesies from patients receiv-
patients that have decreased organ function or limited ing veterinary care, and the addition of analgesie drugs
organ reserve. The incidence of cardiovascular com- to sedative protocols is appropriate in most patients.
plications and long-term effects on organ function will Neuroleptanalgesic combinations (those that com-
be reduced by this simple measure. bine tranquillizers with analgesies) are usually good
In general, any of the drug combinations dis- combinations for procedures that require sedation.
cussed in the preanaesthetic section would be Their disadvantage is that patients who seem asleep
appropriate for physical restraint. Patient age, size, may startle at loud noises. A quiet environment is
temperament and physical condition and the diag- essential when using these combinations. They are
nostic or surgical procedure, its dura ti on, anticipated generally used in young healthy patients, but may be
complications, adverse effects and post-procedural used with caution in elderly or sick patients. Use of
analgesia should all be considered when choosing local anaesthetic techniques such as li ne, ring, conduc-
drugs for sedation. tion and regional blocks or extradural analgesia may
Route of drug administration influences the time greatly enhance patient comfort for minimally inva-
necessary before peak drug effects are observed. Drugs sive surgical procedures.
given subcutaneously may take 30to 60 minutes, drugs The addition of an anticholinergic may be appro-
given intramuscularly may take 15 to 30 minutes, and priate with any of the following combinations. The
drugs given intravenously may take 1 to 5 minutes dose ranges given in the premedication section are
before peak effect. To avoid inadvertent overdose, applicable for sedative protocols. Doses should al ways
additional drugs should not be given until peak effects be adjusted to meet individual patient needs.
are observed. If additional drugs are necessary to Examples of neuroleptanalgesic combinations
sedate a patient, initial drug effects may be waning include:
while additional sedatives are taking effect. It may be
wise to postpone a procedure if adequate sedation does Oxymorphone and acepromazine
not occur after the first or second dose of sedatives. A Butorphanol and acepromazine
quiet environment is essential for any sedative combi- Fentanyl and fluanisone
nation to be effective. Fentanyl and droperidol
In ail cases where restraint is used, patients must Morphine and acepromazine
be positioned comfortably and padded appropria tely. Pethidine and acepromazine
This decreases the amounts of drugs necessary to Buprenorphine and acepromazine.
keep patients from moving during procedures .
Patients may initially resist positioning, but gentle Combinations of benzodiazepines and opioids may be
quiet physical restraint will usually settle patients more appropriate in paediatric, geriatrie or compro-
and they go on to tolerate the procedure without mised patients. Benzodiazepines have very little effect
additional tranquillizers. upon the cardiovascular system and can be used in
It is important to consider all drug effects when patients with decreased organ reserve. With the addi-
choosing protocols for sedation. Sorne drug effects tion of a local anaesthetic technique, these combina-
may alter the results of diagnostic procedures. Opioids tians are good choices in geriatrie patients undergoing
may cause panting, and motion will be increased skin biopsy. The addition of an anticholinergic may be
during radiography. Xylazine may cause the accumu- appropriate with any of the foilowing combinations.
lation of gastric gas in large breed dogs and influence The dose ranges given in the premedication section are
upper gastrointestinal radiography. Acepromazine applicable for sedative protocols. Doses should always
has no analgesie effects and is not suitable on its own be adjusted to meet individual patient needs.
for painful procedures such as wound debridement or Examples ofbenzodiazepine-opioid combinations
skin biopsy. include:
84 Manual of Small Animal Anaesthesia and Analgesia

Midazolam and butorphanol ies from ketamine sedation can be qui te s torm y and it
Midazolam and buprenorphine is recommended that a tranquillizer be used in com-
Midazolam and oxymorphone bination with ketamine.
Diazepam and butorphanol Ketamine is reportedly compatible when mixed in
Diazepam and buprenorphine syringes or intravenous tubing with:
Diazepam and oxymorphone.
5 % Dextrose in water
Diazepam should be adrninistered intravenously and 0.9% Saline
should not be mixed in syringes with any other drugs Xylazine.
The a.2-adrenergic agonists, especially medeto-
midine, may provide adequate sedation and analgesia Ketamine is reportedly incompatible when mi xed in
when used alone. If sedation or analgesia are not syringes or intravenous tubing with:
adequate with xylazine or medetomidine, combina-
tions with opioids or benzodiazepines may be used. Barbiturates
Use caution when combining ~-agoni sts with other Diazepam (it is, however, common practice to
potent tranquillizers, and their use with acepromazine mi x diazepam (or midazolam) and ketarnine in
is not recommended. The pre-emptive use of an anti- the same syringe immediately before
cholinergic may be appropria te with any of the follow- administration, with no apparent adverse effects.
ing combinations. The dose ranges given in the Solutions in which a precipitate has formed
premedication section are applicable for sedative should not be given).
protocols. Doses s hould always be adjusted to meet
individual patient needs. The pre-emptive or concurrent use of an anticholiner-
Examples of ~-agonist combinations include: gic may be appropria te with any of the following drug
combinations . The dose ranges given in the premedi-
Xylazine and butorphanol cation section are applicable for sedati ve protocols.
Xylazine and buprenorphine Doses should always be adjusted to meet individual
Xylazine and butorphanol and midazolam patient needs. Examples of ketarnine combinations
Medetomidine and midazolam used in cats for sedation include:
Medetomidine and butorphanol
Medetornidine and butorphanol and diazepam
Midazolam and ketamine
(diazepam should be adm inistered intravenously
Butorphanol and ketamine
and should not be mixed in syringes with any
Xylazine and ketamine
other drugs).
Acepromazine and ketamine
Medetomidine and ketamine
Ketamine (see also Chapter 8) Oxymorphone and ketarnine
In cats, ketami ne is frequently used in combinations
Oxymorphone and acepromazine and ketamine
designed for chemical restraint. The use of ketamine
Butorphanol and midazolam and ketamine.
for chemical restraint in dogs is not recommended.
When used in sedative and premedication combi-
nations, effective doses of ketamine in cats range
from 3 to 11 mg/kg i.m. or 2 to 4 mg/kg i.v. Ketamine SUMMARY
is a dissociative drug that has anaesthetic and
analgesie properties. Administration of ketamine There are many drug combinations that can be used to
results in a central release of catecho lamines that sedate patients for diagnostic and minor procedures.
indirectl y s timul ates card iovasc ular fun ction. Drug dosages and combinations should be tailored for
Ketami ne inc reases card i.ac output, heart rate each individual patient based on their physical status
and blood pressure in normal patients. However, and the requirements of the procedure. The goal of
catecholamine-depleted patie nts w ill experience sedation is to provide adequate analgesia and tranquil-
negati ve inotropic effects due to the direct effects lization so that the procedure may be accomplished
of ketamine on the heart. without unnecessary stress or physiological compro-
Increased muscle tone and hypersalivation are mise to the patient.
also associated with ketamine. Pinnal, palpebral,
laryngeal and pharyngeal refl exes are not abo lished.
The eyes remain open and s hould be protected with FURTHER READING
steri le lubricant. Ketamine can also cause increases
in intracra nial and intraocular pressures. lt s hould Booth NH ( 1982) Drugs acting on the central nervous system.
l n: Veterinary Pharmacology and Therapew ics, s•• edn, ed.
be avoided in patients with a pre-existing seizure NH Booth and LE MacDonald, pp. 149- 352. Iowa State University
disorder or uncontrolled hyperthyroidism. Recover- Press, Ames
Premedication and Sedation 85

Gleed RD (1987) Tranquilizers and sedatives. ln: Princip/es and Wilkins, Baltimore
Practice ofVeterinary Anesthesia, ed. CE Short, pp. 16-2 7. Williams Short CE ( 1987) Neuroleptanalgesia and alpha-adrenergic receptor
and Wilkins, Baltimore analgesia. In: Princip/es and Practice of Veterinary Anesthesia,
LinHC ( J996) Dissociativeanesthetics. ln: LumbandJones' Veterinary ed. CE Short, pp. 47- 57. Williams and Wilkins, Baltimore
Anesthesia, 3"1 edn, ed. JC Thurmon et al., pp. 241 - 298. Williams Stoelting RK (1991) Pharmacology and Physiology in Anesthetic
and Wilkins, Baltimore Praclice, 2"d ec/n, ed. RK Stoelting. JB Lippincott, Philade lphia
Plumb DC (1995) Veterinary Drug Handbook, 2"" edn , ed. DC Plumb. Thurmon JC, Tranquilli WJ and Benson GJ (1996) Preanesthetics and
Phanna Vet Publishing, White Bear Lake anesthetic adjuncts. ln: Lumb and Jones' Veterinary Anesthesia,
Short CE (1987) Anticholinergics. ln: Princip/es and Practice of 3rdedn ,ed. JCThurmon etal.,pp. 183- 209. Williams and Wi lkins,
Veterinary Anesthesia, ed. CE Short, pp. 8- 15. Williams and Baltimore
CHAPTEREIGHT------------------------------------

Intravenous Anaesthetics
lac ky Reid and Andrea M. No lan

INTRODUCTION Techniques

Indications Single dose


Topping up with increments
For induction of anaesthesia when followed by Continuous infusion.
inhalational agents
As a sole anaesthetic agent for short-term mi nor
procedures such as radiography, suturing, suture PRACTICAL ASPECTS OF
removal or ear examination INTRAVENOUS INJECTION
As part of a total intravenous anaesthetic (TIV A)
technique, where an appropriate intravenous Proper preanaesthetic medication should preclude the
agent is given by repeated boluses or by infusion, necessity for forceful restraint for intravenous injec-
often in conjunction with analgesies tion. In seriously debilitated or aged animais, where
As a supplement to inhalation anaesthesia sedative premedication may be minimal or omitted
To aid in the treatment of conditions such as altogether, gentle handling by a competent assistant
tetanus and status epilepticus should be ali that is required.
Occasionally to provide long-term sedation of
animais in intensive care units. Site
The easiest vein for injection is the cephalic (radial)
Advantages vein. The recurrent tarsal (saphenous) vein may be
used, but restraint is more difficult and the animal's
Simple response to the anaesthetic agent cannot be observed
Cause a rapid onset of anaesthesia so easily . The external jugular vein is not recom-
Relative!y pleasant for the animal mended for injection unless it is catheterized, since it
Do not require special equipment (except in the is much more difficult to ensure that ali the drug is
case of infusion techniques) deposited slowly intravenously, and therefore there is
Pose no danger from explosion or pollution a tendency to administer drugs too rapidly by this
Non-irritant to airways. route. In the cat, should attempts to obtain intravenous
access fail in both cephalic veins, there is an easi ly
Disadvantages accessible superficial vein on the inner aspect of the
thigh (medial saphenous vein). In dogs with large
Superficial veins may be difficult to find external ears, such as BassetHounds, there are veins on
Intravenous access may be difficult to maintain the pinnae that are an option for catheterization should
unless an intravenous catheter is used the veins on the legs prove inaccessible.
Drug may be irritant if given perivascularly
Once injected the drug cannot be removed Equipment
Drug may be cumulative For a single injection, a suitable gauge hypoderrnic
If the animal is not intubated, the airway is needle will suffice, but if repeated injections or an
unprotected and there may be a ris k of aspiration infusion are contemplated, an over-the-needle catheter
of foreign material - tracheal intubation is should be used. This will ensure that the vein is not
mandatory for long procedures and for damaged and that the drug is not injected perivascularly.
emergency resuscitation There are a wide variety of Teflon catheters available
Possible apnoea on injection and choice depends on persona! preference. It is worth
Possible hypotension on injection emphasizing, however, that for successful placement
Possible excitement in recovery. of these it is best to make a small nick in the skin so that
88 Manual of Small Animal Anaesù1esia and Analgesia

the point of the catheter is not damaged as it passes barbiturates, causes rapid loss of consciousness.
through the skin. As the inner needle enters the vein, The principal factor that limits the time to the
blood 'flashes bac k' into the hub of the needle, and the onset of anaesthesia is the circulation time from
catheter should then be advanced into the vein white the site of injection to the brain
the needle is held firmly. The catheter should then be Thiopentone causes respi ratory depression and,
capped, flushed with heparinized saline and secured by occasionally, apnoea
adhesive tape. Thiopentone causes cardiovascular depression.
To facilitate the infusion ofintravenous anaesthetic Hypotension and a reduction in cardiac output
agents, it is advisable to use either a volumetrie infu- are observed after intravenous injection. The
sion pump or a syringe dri ver - many of which are overall effect depends on the rate of drug
available. Volumetrie infusion pumps are generally administration and the total dose administered,
used fo r the administration of fluids in veterinary the animal 's condition (blood volume, acid-base
practice. Wh ile they can be used to infuse intravenous balance etc.) and concurrent administration of
anaesthetic drugs, they are not ideal, and frequently drugs that affect the cardiovascular system e.g.
drugs have to be diluted or given through a burette acepromazine. Tlùopentone has a direct
giving set. Syringe drivers are more flexible and are myocardial depressant action, which is minimal
ideal for giving drugs by infusion. They take a selec- at normal clinical doses but can be severe with
tion of syringe sizes and afford excellent control over high plasma concentrations of the drug.
the adminjstration rate (see Chapter 4). Hypovolaemia ma kes animais very susceptible to
the myocardial depressant action of the
barbiturates. Peripheral vasodilation is the
BARBITURATES primary reason for arterial hypotension. Cardiac
arrhytlunias may be noticed during induction of
Thiopentone sodium (thiopental) anaesthesia, but are generally innocuous in
Thiopentone is a highly lipid-soluble weak organic healthy animais
acid supplied as its sodium salt in powder form Recovery from thiopentone anaesthesia is
whlch, once made up with sterile water, is stable for dependent upon redistribution of the drug to
3-7 days depending on temperature. It is licensed for other tissues. After a single injection of
use in dogs and cats. The solution is very a lkaline (pH thiopentone, plasma concentrations decline
14) and is highly irritant if the concentration is grea ter rapidly in a tri-exponential manner, as the drug
than 2.5%. It is not miscible with acidic drugs as is redistributed from the brain to other tissues of
precipitation occurs. Once injected into blood (pH the body. Initially, the drug is taken up by
7.4), the drug repartitions from its almost totally re latively weil perfused tissue such as brain ,
ionized form. At pH 7.4, 6 1% of a given dose of heart and kidney. Thus anaesthesia is induced
thiopentone exists in the unioni zed form. Thlopen- (as brain concentrations increase) and the
tone is approximately 80 -85 % bound to plasma plasma concentration starts to decrease. Soon
proteins. As with ali anaesthetic drugs, only the after, moderately perfused tissues, such as
unbound unioni zed fraction of the drug is able to muscle, take up drug and this contributes to a
penetra te cell membranes and th us produce its effect. further decrease in plasma thiopentone
Therefore, the response to a given dose of the drug concentrations. At this time the plasma
may vary depending on the pH of the blood. At concentrations may be sufficiently low to
normal blood pH, 39 % of a given dose is ionized, but reverse the concentration gradient between the
thls percentage decreases as pH falls. Thus the non- brain and the plasma in favour of drug leaving
ionized fraction increases and consequent!y acidosis the brain, when consciousness soon returns.
will enhance penetration of the blood-brain barrier. Poorly perfused tissues, such as adipose tissue,
The concentration of plasma pro teins wi Il a Iso affect take up drug s lowly, as the blood flow to them
dose requirements. Hypoproteinaemia or uraemia is poor. However, the tota l capacity of fat for
(which results in displacement of the drug from lipid-soluble drugs such as thiopentone is high
binding sites) will increase the percentage ofunbound, and so this tissue can 'store' thiopentone.
and therefore active, drug and, in severely affected Metabolism of thiopentone occurs slowly in the
animais, dose requirements wi ll be reduced. Thio- li ver. Animais recover from anaesthesia (after a
pentone crosses the placenta readily, and feta l tissues single bolus dose) when most of the drug
will rapidly equilibrate with the maternai blood. present in the body is partitioned into tissues.
As this leaches out into plasma, dogs and cats
Properties may seem to be 'groggy', and full recovery may
appear long, since the li ver cam10t metaboli ze
Thlopentone crosses the blood-brain barrier the drug re-emerging from tissues fast enough
rapidly and, like other ultra-short-acting to prevent sorne depression of the central
Intravenous Anaesthetics 89

nervous system (CNS). Low clearance values of one-half and two-thirds the calculated dose, and to
1.5-3 .2 ml/kg/min have been reported in the wait to obtain the maximum effect before proceeding
dog, and the drug is unsuitable for use to with increments . An even slower rate of injection
maintain anaesthesia. Repeated administration should be used in s ick animais (60 seconds or more).
leads to cumulation of the drug because tissue In cats it may be necessary to give the drug slightly
sites become saturated. Tllis causes potentially more quickly as they tend to struggle more while
serious cardiovascular and respiratory effects being restrained. After a single intravenous dose,
and delayed recovery from anaesthesia anaesthesia lasts 5- 15 minutes. Its use for the main-
.Thiopentone is an irritant if injected tenance of anaesthesia is not recommended due to the
perivascularly. It should be used in as dilute a s low metabolism of the drug. This leads to c umula-
solution as is compatible with a reasonable tian of thiopentone in various body tissues, including
injection volume (1 -2 .5 % in small animais) fat, and consequently a prolonged recovery time.
Thiopentone has poor analgesie properties. It Apnoea on induction of anaesthesia with thiopentone
was considered to be hyperalgesic, i.e. lowered is common. If this persists, the animal should be
the threshold to painful stimuli, although recent ventilateèl until spontaneous breathing resumes. Thio-
work has cast doubt upon this . Relatively deep pentone should be used with extreme care in
anaesthesia is required with thiopentone to cardiovascularly compromised animais, when both
suppress responses to surgical stimulation the dose and the rate of administration should be
Thiobarbiturates should be used with care in reduced. Rapid intravenous injection of a fu ll dose of
Greyhounds and other 'sight' hounds. Recovery thiopentone in these animais results in a precipitous
from anaesthesia is longer in Greyhounds than in fa li in arterial blood pressure. If thiopentone is used
mixed-breed dogs. This correlates with high to induce anaesthesia after xylazine or medetomidine
plasma thiobarbiturate concentrations reported in premedication, the dose should be markedly decreased
this species (around 75-90% reduction).
Thiopentone may be displaced from plasma
protein binding sites by drugs that are more Methohexitone sodium (methohexital)
strongly protein bound, such as the non-steroidal This oxybarbiturate is supplied as its sodium salt in a
anti-inflammatory agents, e.g. phenylbutazone powder, which when made up in sterile water is rela-
and flunixin. In theory this may lead to an tive!y stable for about 6 weeks. It is highly alkaline,
increased pharmacological effect twice as patent as thiopentone and is generally adnlin-
Thiopentone reduces intracranial pressure in istered as a 1-2.5% solution. Protein binding is similar
humans with elevated intracranial pressure, and to that measured for thiopentone (80-85 %).
may be indicated in patients with intracranial
tumours. However, attention must be paid to Properties
avoiding hypoventilation, which may be
induced by the barbiturates, as the resulting Ultra-short-acting barbiturate that induces a rapid
hypercapnia will have the effect of increasing Joss of consciousness
intracranial pressure. Barbiturates produce no Post-induction apnoea is more common than
significant alteration in intracranial pressure in after thiopentone
normal patients Cardiovascular depression similar to
Thiopentone is an effective anticonvulsant (but thiopentone. Some work has suggested that in
the side effects of hypotension and respiratory cats the hypotensive effect is greater than with
depression mean that animais need to be thiopentone, while the opposite is the case in
carefully monitored). humans. In both species the differences are small
Recovery from anaesthesia is dependent on both
Use redistribution and metabolism (three times as fast
Thiopentone is used as an induction agent in ali as thiopentone in the dog; clearance around 11
species. It is important to give the drug to effect and mlfkg/nlin). Redistribution of drug occurs in a
not to give a computed dose, sinee each individual ' s manner similar to that of thiopentone. However,
requirements will vary. However, as a guide, in as drug diffdses out of tissues, hepatic
unpremedicated fit animais, a dose of around 20-25 metabolism clears the plasma of methohexitone
mg/kg may be required to produce unconsciousness considerably more rapidly than it does with
sufficient to permit endotracheal intubation. This thiopentone, and consequent! y there is Jess of a
dose is halved by the use of premedicants . The dose 'hangover' effect
should be given slowly (over 30-40 seconds) so that It is Jess irritant than thiopentone if injected
the injection may be stopped once the desired effect perivascularly
is obtained. The optimal method for administering It has poor analgesie properties, sinlilar to
thiopentone to induce anaesthesia is to give between thiopentone
90 Manual of Small Animal Anaesthesia and Analgesia

Muscular twitching is often seen at induction and convulsions. Care must be taken to ensure adequate
recovery ventilation. Induction of anaesthesia should be per-
Spiking activity seen on an formed slowly to allow time for the drug to cross into
electroencephalogram (EEG) is of questionable the brain before topping up.
significance. Although methohexitone is not
contraindicated in epileptic patients, thiopentone
would be a better choice. STEROID ANAESTHETICS

Use Alphaxalonefalphadolone
Methohexitone, li ke thiopento ne, s ho uld be given to A lphaxa lonejalphadolone is a mi xture of two proges-
effect. On average, approximately 5 mg/kg is required terone deri vati ves, a lphaxalone (9 mg/ml) and
to produce unconsciousness in premedicated animais, alphadolo ne acetate (3 mg/ml). Alphaxalone is a
but it is best to give approximately halfthis initia li y and cons ide r ably m o r e potent a naesthetic than
then top up, incrementally, to effect. Methohexitone is alphadolone. These drugs are not water soluble and
mainly used as an induction agent, but due toits rapid are thereforesolubilized by the useof20% 'Cremophor
metabolism it can be used to maintain anaesthesia with EL' (polyoxyethylated castor oil). The solution is
incrementai dosing or by infusio n, without prolo nging clear but viscous and of a neutra! pH. Once opened,
recovery. Approximately 0.3 mg/kg/min will gener- vials should be used at once since no bacteriostatic
ally maintain anaesthesia. agent is included in the preparation. The solution
Methohexitone does not cause prolonged recovery shou ld not be stored in the refrigera tor, as the steroids
in Greyho unds and related breeds and is therefore pre- tend to precipita te o ut of solution. The drugs are not
ferred to thiopentone for these animais. It tends to be highly plasma protein bound (<50%) and so the
used selective!y in small animais where a rapid recovery effects of a given dose of alphaxalonejalphadolone
is required, e.g. brachycephalic dogs. Excitement and are not likely to be enhanced by the presence of
muscular twitching at recovery may be evident. This hypoproteinaemia. The drug is not licensed for use in
may be reduced by the use of adequate premedication. dogs, as they may exhibit a potentially fatal anaphy-
As with thiopentone, caution should be exercised when lactoid reaction to the castor oil. The reported use of
using methohexitone in animais inshock, and in animais the drug, in combination with large doses of antihis-
premedicated with ~-adrenoceptor agon.ists such as tam ines, seems an unnecessary and dangerous choice
xylazine and medetomidine. when other safer drugs are available for dogs. In cats,
bircls and small Jaboratory anima is alphaxalone/
Pentobarbitone (pentobarbital) alphadolo ne is ad ministered by intravenous or intra-
Pentobarbitone is an oxybarbiturate, very similar in muscular injection.
structure to thiopento ne. It is less lipid soluble and is ·
available as pentobarbitone sodium as a 6% solution Properties
(60 mg/ml), which is alkaline. Binding to plasma
proteins is low (around 40%) . It is licensed fo r use in High therapeutic index and wide safety margin
dogs and cats as a sedative and as a general anaesthetic. Short acting. Both steroid components are
metabolizecl rapidly by the liver. The cluration
Properties of action of a s ingle dose of the drug is
therefore short (5- 20 min utes depencling on the
Slow onset of action (60-90 seconds) due to close) and recovery is rapid. However, in cats
lower lipid solubi lity compared with thiopentone with hepatic dysfunction, metabolis m is likely
and methohexitone to be delayed and the drug will have a
Post-induction apnoea and respiratory depression prolo nged dura ti on of action. Renal clysfunction
are features of this drug when it is used as a sole may delay recovery. Rapid Joss of
anaesthetic agent consciousness after intravenous injection (as for
Cardiovascular depression can be profound thi opentone and propofol) or deep
Recovery from anaesthesia is slow due to a intramuscular injection. Suitable for use in total
combination of lim ited redistribution (as a intravenous anaesthesia
consequence of low lipid solubility) and s low Cardiovascular depression - hypotension similar
metabolism to thiopentone
An irritant if injected perivascularly Mild respiratory depression, although apnoea is
Poor analgesie properties. rare
Good muscle relaxation
Use Little tissue toxicity if injected perivascularly
Pentobarbitone is not recommended for genera l anaes- Anaphylactoid reactions occur in some cats
thesia in s mall animais. It has been used to control given alphaxalonejalphadolone. The severity of
Intravenous Anaesthetics 91

these reactions varies from mild subcutaneous acid-base balance, respiratory and cardiovascular
oedema of the paws and pinnae to more severe function and body temperature).
laryngeal and pulmonary oedema and profound
hypotension. Although fatalities are rare, it is
probably best to avoid using the drug when DISSOCIATIVE AGENTS
airway surgery is contemplated or if the animal
has a history of atopy Ketamine
Like ali anaesthetic agents, alphaxalone/ Ketamine hydrochloride is presented in aqueous solu-
alphadolone will cross the placenta and cause fetal tion. It is a weak organic base and the hydrochloride
depression. In cats requiring Caesarian section, its solution has a pH of 3.3-5.5, so that it is not miscible
use should therefore be confined to the induction with alkaline solutions. The drug is formulated at a
of anaesthesia. Sufficient time should be allowed concentration of 100 mg/ml in 5 ml or 10 ml multidose
for redistribution of the drug from the kittens vials. It is relatively stable for 3 years, but botties
before they are delivered (see Chapter 18). should be protected from light and excessive heat. The
preparation is a racemic mixture, with the stereo isomers
Use producing different spectra of actions. Ketamine can
Widely used in the cat, smalllaboratory animais and be administered by intramuscular, intravenous, subcu-
birds. Its high therapeutic index makes it a useful taneous or intraperitoneal injection, and also it can be
anaesthetic for induction and maintenance of anaes- given orally.
thesia in the cat. Dissociative anaesthetics depress the cerebral cor-
tex before causing medullary depression. Dissociative
lnh·amuscular route: Inject into a suitable muscle anaesthesia is a state whereby profound somatic anal-
mass. The quadriceps group is usually preferred to gesia is combined with a light plane of unconscious-
other leg muscles because there are fewer intermuscu- ness, but the animal seems to be dissociated from its
lar spaces into which the drug may be deposited environment. Pharyngeal, laryngeal, corneal and pedal
inadvertently, and from which absorption will be so reflexes, the abolition of which are conventionally
s low asto reduce the effectiveness of the drug. used to assess depth of anaesthesia, persist relatively
The intramuscular dose can range from 4 mg/kg unimpaired, and the eyes remain open. In humans,
(suitable for premedication before topping up by the dreams and emergence hallucinations are features of
intravenous route sorne 10 minutes later) to 18 mg/kg, its use, and the administration of dissociative agents is
which will induce full anaesthesia within 10-15 min- largely restricted to young children. This picture can be
utes. However, the highest dose represents a consider- modified by the use of a 2-adrenoceptor agonists
able volume, which can be difficult to inject. A median (xylazine, medetomidine) or benzodiazepines (di-
dose of around 9 mg/kg is used more usually and this azepam, midazolam) as premedicants. Ketamine is
will produce sufficient restraint, with the option of rapidly metabolized in the dog and cat by hepatic
increasing the depth of anaesthesia by giving further microsomes. The main metabolite, norketamine, has
drug intravenously. More than one injection site may hypnotic properties (approximately one-fifth as potent
be required in large cats. as ketamine in this respect) and has a half-life longer
than that of ketamine. This may explain the occasional
Intravenous route: As with ali induction agents, drowsiness and prolonged recoveries in ani mals when
alphaxalonefalphadolone is best administered intra- large doses of ketamine have been given.
venously, to effect. In healthy animais, approximately
6 mg/kg will induce anaesthesia sufficient to permit Properties
endotracheal intubation. For a short period of
anaesthesia, sufficient for minor procedures (10 Rapid induction following parenteral
minutes), a further 3 mg/kg may be administered administration, although the rate of onset after
slowly until the desired depth of anaesthesia is intravenous injection is markedly slower than
achieved. In debilitated or old animais, this further after thiopentone
dose is not usually required. If alphaxalone/ Little cumulation reported, although infusions of
alphadolone is used as the sole anaesthetic agent, ketamine have not been widely used in dogs and
small (around 0.5 ml) increments may be injected as cats. Clearance values are lùgh (38-40 ml/kg/
necessary to maintain anaesthesia, or an infusion may min). Ketamine is metabolized rapidly by the
be set up to deliver the drug at a rate of around liver, and both parent compound and metabolites
0.24 mg/kg/min (i.e. 0.02 ml/kg/min). Because the are excreted in bile and "via the kidneys. Hepatic
drug is eliminated rapidly by hepatic metabolism, dysfunction affects elimination of the drug and
repeated doses do not pralong recovery, even after prolongs its action considerably. Renal
24 hours anaesthesia/sedation, provided normal dysfunction may delay the excretion of
homeostasis has been maintained (i.e. fluid balance, norketamine, which may contribute to drowsiness
92 Manual of Small Animal Anaesthesia and Analgesia

The respira tory effects of ketamine in the dog to offset these and other side effects. In the dog,
and cat are interesting. There is a degree of combinati ons of midazolamjketamine and diazepamj
respiratory depression initially and often ketamine have been used for short-term anaesthesia
periodic breath-holding on inspiration, giving and also for induction of anaesthesia before mainte-
rise to a so-called 'apneustic' pattern of nance with an inhalational agent. The minimal
respiration. Generally, arterial blood oxygen cardiovascular and respiratory effects produced by
tensions are weil maintained (compared with this combination make it suitable for use in poor risk
barbiturates), and the preservation of cardiac cases. Other sedatives that have been combined with
output also allows tissue oxygenation to be ketamine for use in dogs include acepromazine and
well maintained the a. 2 -adrenoceptor agonists, xy laz ine and
Cardiovascular effects are dose related. Central medetomidine. More recently, the combination of
stimulation of the sympathetic system leads to a medetomidine, butorphanol and ketamine has been
tachycardia and increase in blood pressure and advocated as suitable for use in dogs. Ketamine
cardiac output. Large doses given intravenously seems to reduce the undesirable cardiovascular
may produce a transient fall in blood pressure effects of medetomidine in small animais. In the cat,
as the drug produces a direct but transient ketamine is generally combined with xylazine or
depression of the myocardium. Normally the medetomidine or with a benzodiazepine tranquillizer
hypertensive effects predominate unless very such as midazolam. The combination produces satis-
large doses are used. Peripheral resistance does factory anaesthesia for many surgical procedures. It
not increase. Studies in dogs and cats have may be useful in uncontrollable cats, where its rapid
indicated that ketamine does not induce absorption from any site (including the oral mucosa)
cardiac arrhythymias and may be anti- allows for ease of administration (see Chapter 7 for
arrhythmic. The increase in blood pressure further details).
produced by ketamine makes it unsuitable for
intraocular surgery Cats
Good analgesia. Ketamine has been used Sedationjanaesthesia in combination with midazolam:
successfully in humans as an analgesie for
phantom limb pain and also for burns. In By intramuscular injection: 0.2 mg/kg
veterinary medicine, it may also prove useful at midazolam and 10 mg/kg ketamine
subanaesthetic doses for intractable pain and as By intravenous injection: 0.2 mg/kg midazolam
an adjunctive analgesie in TIV A techniques (see and 5 mg/kg ketamine- given slowly to effect.
Chapter 6)
Causes increase in muscle toue. Spontaneous General a naesthes ia in combination with
involuntary muscle movements, which may medetomidine:
progress to tonic-clonic spasm of limb muscles,
are frequent! y observed after administration of By intramuscular injection: medetomidine
ketarnine alone in small animais 80 11g/kg and ketamine 2.5-7.5 mg/kg
Salivation and lacrimation are increased By intravenous injection: medetomidine
Laryngeal and swallowing reflexes tend to 40 11g/kg with ketamine 1.25 mg/kg.
persist
If used as a sole agent in dogs (unlicensed for General anaesthesia in combination with medetomidine
such use), convulsions are frequently observed. It and butorphanol:
is interesting to note that ketamine has been
shown to have anti-epileptic properties in sorne By intramuscular injection: butorphanol
species 0.4 mg/kg, medetomidine 80 11g/kg and ketamine
Ketamine increases cerebral blood flow and 5 mg/kg
cerebral oxygen consumption, which may have By intravenous injection: butorphanol 0.1 mg/kg,
serious adverse consequences in animais with medetomidine 40 11g/kg and ketamine
raised intracranial pressure. 1.25-2.5 mg/kg.

Use Dogs
It is doubtful if ketamine alone is of use for surgical Sedationjanaesthesia in combination with diazepam:
procedures in veterinary practice, although it is li-
censed for such use in cats and subhuman primates. By intravenous injection: 1 ml/10 kg of a 50:50
The increased muscle tone and incidence of convul- mixture of diazepam and ketamine (0.25 mg/kg
sions at high doses, particularly in the dog, are diazepam, 5 mg/kg ketamine) given slowly to
undesirable properties and, clinically, ketamine is effect works weil after sedative premedication
used in combination with a sedative or tranquillizer (premedication smooths recovery).
Intravenous Anaesthetics 93

General anaesthesia tn combination with Res piratory depression and irregular breathing
medetomidine: patterns are dose related.

By intramuscular injection: medetomidine Dose of combination


40 !Jg/kg and ketamine 5.0-7.5 mg/kg. Wide dose ranges have been described, depending on
the physical status of the animal, the degree of restraint
General anaesthesia in combination with medetomidine required (low doses produce chemical restraint) and
and butorphanol: the duration of the surgical procedure. The following
are intended as a guide.
By intramuscular injection: butorphanol
0.1 mg/kg and medetomidine 25 !Jg/kg, followed Dogs
15 minutes later by ketamine 5 mg/kg.
2-13 mg/kg i.m. or i.v.: onset time 30-60
Problems seconds after intravenous injection and within
5-12 minutes after intramuscular injection.
Recovery from ketamine alone can be stormy,
especially in cats. Disturbances such as noise, Cats
lights and handling may precipitate seizures
Hypothermia and delayed recovery may occur, 2- 15 mg/kg i.m. or i.v.: onset time as for the
especially in cats, which is probably related to dog. Sorne cats show pain on intramuscular
large doses given intramuscularly. It is important injection.
to keep the ambient temperature high in the
recovery area Increased salivation is a feature of its use, but this can
The depth of anaesthesia may be di ffi cult to be prevented by the prior administration of atropine or
judge, and inexperienced observers may glycopyrrolate.
conclude, wrongly, that supplementary drugs
(including volatile agents) are required. Any
additional anaesthetic drug may produce marked PROPOFOL
respiratory depression and must be administered
with great care Propofol is a substituted phenol, presented as an emul-
Corneal drying may occur because the eyes sion (10 mg/ml) and administered intravenously.lt is
remain open, and a bland ophthalmic ointment licensed for use in the dog and cat, bath for bolus
should be applied administration and for incrementai injection.
The administration of xylazine or medetomidine The pharmacokinetics of propofol have been weil
in combination with ketamine carries the risk of described in humans and reasonably weil described
vomiting at induction, and this combination must in healthy dogs, but not in cats. The pharmacokinetic
not be used in those cases with gastrointestinal properties of pro pofol are unique and contribute toits
obstruction. clinical advantages. Propofol is rapidly cleared from
the body (clearance >40 ml/kg/min) by metabolism,
Tiletamine approximately 10-20 times faster than thiopentone.
Tiletamine is chemically very closely related to Evidence is accumulating that extrahepatic metabo-
ketamine and its pharmacodynamie effects are lism of propofol occurs in humans, sheep, goats and
similar, but it is longer lasting, more patent and has dogs. After bolus intravenous injection of propofol,
more pronounced side effects (muscle rigidity and plasma concentrations decrease rapidly due to redis-
tonic-clonic seizures) th an ketamine. Consequent!y it tribution of drug to the brain and other highly perfused
is marketed for clinical use in combination with tissues, such as muscle (similar to thiopentone). There-
zolazepam, a benzodiazepine tranquillizer, which is after, the decrease in propofol plasma concentration
an effective anti-convulsant and muscle relaxant. The is faster than for thiopentone due to rapid metabolism
combination is available in the USA but not in of the drug. The elimination half-life of propofol is
the UK. In the dog, the tranquillizing effects of the long (values up to 330 minutes in dogs have been
zolazepam seem to wane before the effects of reported), but this is not clinically relevant and prob-
the tiletamine, and so recoveries can be stormy, ably reflects the slow elimination of propofol from
especially with high doses and in the absence of fat. Propofol, like thiopen):one, has a large volume of
sedative premedication. In the cat, the reverse a pp lies distribution, i.e. it distributes widely through body
because of the long plasma half-life of zolazepam, tissues, as would be expected for a lipophilic drug.
and recoveries are twice as long as those seen in Propofol is metabolized to sulphate and glucuronide
the dog. Tachycardia with zolazepam/tiletamine conjugates of a quinol derivative of propofol, which
occurs more frequently in the dog than in the cat. are inactive.
94 Manual of Small Animal Anaesthesia and Analgesia

Properties an intravenous infusion of propofo l, w itho ut a lter-


ing the quality or duratio n of recovery. Apnoea at
Short acting (anaesthesia lasts approx imately ind uction is frequently observed, s ince propofol,
5-8 minutes after bolus injection); rapid onset of like thiopentone and methohexitone, is a respi ratory
anaesthesia, as for thiopentone d epressa nt. T his may be related to the speed of
Respiratory depressio n (post-induction apnoea is injection of the drug; t he s lower the injectio n, the
frequently observed) lower the incidence of a pnoea. Where necessa ry, the
Cardiovascular depression - hypotens ion due to anima l should be ventilated s lowly until s ponta-
mild myocardial depression and periphera l neo us breathing recommences.
vasc ular dilation O ld anima is have a reduced d ose requ irement for
Rapid and smooth recovery - due to propofol. P re li m i nary ev idence s uggests that
redistribution and rapid metabolism of the drug. propofol induces resp irato ry depression in puppies
The sa me princip les of redistribution of titis de livered by Caesari an section w hen the bitch has
lipopllilic drug apply as for thiopentone. The lack been anaesthetized with propofol. H owever, pro-
of ' hangover' effect, wllich is a key feature of vided low doses are used, it is probably satisfactory
recovery from propofol anaesthesia, is due to the (see C hapter 18). It s ho uld be used w ith ca re in
rapid metabolism of propofo l as it returns from animais in s hock, i.e . the dose and s peed of injectio n
tissue sites into blood s hould be reduced to avoid a s udden decrease in
Suitable for use as a maintenance agent. peripheral vascular resis tance and myoca rdia l de-
Infus ions of propofol for up to 4 ho urs have pression, leading to cardiovascular collapse. The
been reported in dogs, and s horter infus ions authors use propofol in an ima is with severe hepato-
have been reported in cats. T he pathy at a reduced dose rate w ith few com pl icatio ns .
pharmacokinetics of propofol make it After inducti on of anaesthesia w ith propofol , there
particu larly attractive for use by infus io n and, is little reductio n in renal blood flow. T hi s is in
for inf usions of less than 2 hours, propofol has contrast to thiopentone and ali the vo la ti le anaes-
been s hown to be highly satisfactory. In th etic agents, a nd t herefore p ropofo l is probably t he
humans, maintenance of anaesthesia fo r agent of choice in animais w ith compro m ised renal
prolonged periods (8 hours) has been associated function. Experie nce has shown that it is a satisfac-
with fast return of concio usness tory induction agent in puppies as young as 4 weeks.
Fair muscle relaxation, but occas ionally muscle Because of its renal s paring effects and lack of
rig idity is o bserved anaesthetic ' hangover ', it is the drug of choice for
Not irrita nt if injected perivascularly ind uctio n of anaesth esia in geriatrie a nimais.
May have some analgesie properties
Propofol decreases cerebral blood fl ow and Dog
cerebral oxygen consumption, and it seems that
the autoregulatory capacity of the cerebral Induction
circulation remains intact during propofol
anaesthesia. It reduces intracranial pressure in Propofol alone: 5-6 mg/kg i.v. (males seem to
both norma l patients and patients w ith raised require a slightly higher dose than females)
intracranial pressure, although cerebral perfus ion In premedicated dogs: 3-4 mg/kg i. v. (the dose
pressure may be decreased must be reduced markedly where premedi cation
Propofol s howed anti-convulsant properti es used an ~-adrenoceptor agonist (approximately
s imilar to thiopentone in anima l mode ls 1-2 mg/kg)) .
of status epi lepticus. However, the UK
Committee on Safety of Medicines has Maintenance
ad vised anaesthetists to use propo fol w ith
care in humans with epilepsy, beca use of Incrementai doses or by infusion (see be low).
reports of increased EEG epileptifo rm
activity in some patients. Cats

Use Induction
Propofol is used to induce anaesthesia in dogs and
cats. It provides a rapid smoo th induction of anaes- 6-7 mg/kg i. v. (the dose does not seem to be
thesia and a fast excitement-free recovery with no influenced by prior sedatio n with acepromazine).
' hangover' effect. In humans, pro pofol has rapidly A sing le dose produces anaesthesia lasting only
become the drug of cho ice for induction of anaesthe- approximately 10- 15 minutes. The dose must be
sia in outpatients, because of these pro perti es. A n- reduced markedly where premedicatio n used an
aes thesia may be maintained w ith top- up doses or by ~-adrenoceptor agonist.
Intravenous Anaesthetics 95

Maintenance TOTAL INTRAVENOUS ANAESTHESIA


Infusion rates of 0.2- 0.5 mg/kg/min have Total intravenous anaesthesia offers many advan-
been used to maintain anaesthesia. However, tages to the anaesthetist and veterinary surgeon. It is
there are few data on the use of propofol by relatively easy to administer, although intravenous
infusion in cats. Sorne cats exhibit retching access must be secure, and consequently the animal
and sneezing and may paw their faces must have an intravenous cannula placed before
during recovery. induction of anaesthesia. Recovery is primarily
determined by the pharmacokinetic profiles of the
Problems drugs used and can be faster than after inhalation
anaesthesia, where recovery is largely governed by
Occasional transient profound bradycardia after phys icochemical properties such as the blood/gas
intravenous administration solubility coefficient. The use of TIVA eliminates
Due to increased sensitivity in debilitated or old any possible hazards to people associated with
animais, the dose rate needs to be reduced exposure to trace concentrations of volatile and
considerably (2-3 mg/kg) gaseous anaesthetic agents.
Enhanced effect and prolonged duration of action Of ali the anaesthetic drugs currently licensed,
is likely in animais with hypoproteinaemia propofol has a pharmacokinetic profile that makes it
Repeat anaesthesia with propofol in cats the most sui table drug for maintenance of anaesthesia
(daily anaesthesia for 30 minutes for up to 7 by continuous infusion. It has a short duration of
days) has been associated with haematological action, which is related toits redistribution within the
toxicity (increasing Heinz body production), body and its rapid metabolism to inactive substances.
increased recovery times from anaesthesia Pharmacokinetic data from dogs have shown th at it is
and anorexia. cleared rapidl y from the body indicating that, on
recovery from anaesthesia, a considerably smaller
proportion of propofol than, for example, thiopen-
ETOMIDATE tone, is present in the body. It is because of this high
clearance rate that propofol can be used successfully
The imidazole derivative etomidate is recommended to maintain anaesthesia.
for induction of anaesthesia for Caesarian section, Propofol infusions of up to 2 hours have been used
for traumatized patients arid for those with myo- by severa! groups to maintain anaesthesia in dogs
cardial disease, liver disease or unstable haemo- undergoing a variety of surgical procedures. Dose
dynamics. It decreases intracranial pressure in rates of between 0.3 and 0.5 mg/kg/min seem to be
animais with severe intracranial lesions, decreases necessary in premedicated spontaneously breathing
brain oxygen consumption and may have protective dogs to ensure surgical anaesthesia. In Greyhounds,
properties in the face of global ischaemia, making it slower recovery from anaesthesia by up to 2 hours has
a good agent to use for ne urosurgical procedures. been reported after propofol infusion. Delayed recov-
When etomidate is used atone in dogs at doses that ery can arise if anaesthesia is prolonged and the propofol
produce general anaesthesia ( 1.5-3 mg/kg i. v.), heart infusion is not reduced in a stepwise manner over"time.
rate, mean arterial blood pressure and myocardial Propofol infusions in cats have not been studied in
performance remain stable. Side effects include detail. A recent report showing that propofol induced
sneezing, retching, myoclonus, pain on injection toxic side effects in cats when infused for 30 minutes
and phlebitis, but these can be minimized by the use repeatedly over a 7 -day period, may have significance
of adequate sedative premedication. It is rapidly clinically where prolonged infusions are necessary.
metabolized to inactive metabolites in the liver, Propofol may have sorne analgesie properties, but
and its pharmacokinetic characteristics should make for surgery, supplemental analgesia is recommended.
it suitable for administration by repeat bolus or This can be provided by intermittent administration
continuons infusion. Nevertheless, etomidate has or continuous infusion of an opioid drug such as
been implicated in the development of Addisonian alfentanil. However, there are limited data available
crises in intensive care patients during long-term on the use of propofolfalfentanil infusions clinically
infusion for sedation, and it also inhibits adrenal in small animais, and although this combination is
steroidogenesis in dogs. Wh ile this is unlikely to be used frequent! y in hu mans, it is not yet recommended
a problem with a single induction dose of 3 mg/kg, for dogs or cats. It may prove to be a successful
long-term infusion may have serious endocrine technique in mechanicaliy ventilated animais, but it
effects. In practice, continuons infusion of etomi- is unlikely to be used where spontaneous breathing is
date is precluded by haemolysis that is probably desired. Alternative! y, pethidine (meperidine) or mor-
caused by the 35% (v/v) propylene glycol in which phine may be given as a premedicant and topped up
it is supplied. as required during the perioperative period, while the
96 Manual of Small Animal Anaesthesia and Analgesia

use of 67 % ni trous oxide will a Iso redu ce the propofol and cardiovascular im pairment that it is
requirement and provide analgesia. Ma intenance of essential to provide a secure airway and an
anaesthesia with propofol has depressant effects on oxygen enriched atmosphere if hypoxia is to
the cardiovascular and respiratory systems. How- be avoided. Moreover, intermittent positive-
ever, in healthy animais maintained in a light plane of pressure ventilation may be required to
s urgical anaesthesia, theseeffects are mild. The blood avoid severe hypercapnia. Bradyca rdia is
propofol concentration required to maintain anaes- frequently a feature in dogs, and arterial
thes ia has been re a so na bl y we il de fin e d hypotension occurs
and seems to be similar across a range of species The potent narcotic provides good analgesia but,
(approximately 3-7 !Jg/ml, with nitrous oxide, unfo rtunately, administration of a narcotic
depending on the severity of the s urgical procedure; antagonist at the end of surgery not only reverses
5- 10 11g/ml when propofol is used a lone). anaesthesia but also abolishes ali pain relief and
Mo re recent advances in a naesthes ia have renders the further administration of any narcotic
included the development of target contro lled infu- analgesie virtually useless for a considerable
sions (TCI) of propofol. The anaesthetist uses a period of time
computer programmed syringe dri ver that infuses Poor muscle relaxati on
propofol to achieve the desired blood propofol con- In the UK, these are controlled drugs under the
centration. This system is now used in humans. It is Misuse of Drugs Act, 1971. In the USA, they
simple to use and gives excellent control over the are regulated under the Controlled Substances
depth of anaesthesia. Recent work in dogs in the Act, 1970
au thors' hospita l has shawn the usefulness of this Potential for accidentai or deliberate self-
technique, and this re presents a new method of anaes- administration, which may be fatal (applies to
thesia for development in animais in the near future. etorphine hydroch lori de-methotrimeprazine
(see below))
Sensitivity to noise and lights
NEUROLEPTANAESTHETIC May cause defecation and vomition.
MIXTURES
Etorphine and methotrimeprazine
Neuroleptanalgesic mi xtures may be administered in This combination includes 0.074 mg/ml etorphine
large doses so that the anima l becomes virtually hydrochloride and 18 mg/m l methotrimeprazine. It is
unconscious, at which point they may then be loosely marketed with its antagonist, which contains 0.295
termed neuroleptanaesthetic mixtures. Such mixtures mg/ml diprenorphine hydrochloride.
are combinations of a potent opioid and a sedati ve/
tranquillizer drug, and are therefore used only in Dose
dogs. In animais that are old, debilitated or have
moderate to severe systemic disease, the use of pro- 0.05 ml/ kg i.v.
prietary combinations should be avoided. Proprietary 0.1 mljkg i.m .
combinations should not be confused with home
made neuroleptanalgesic mixtures (e.g. acepromazine Onset
and pethidine for sedationjpremedi cation, or fentanyl
and diazepam for induction of anaesthesia). Further Immediate after intravenous administration
details on the use of neuroleptanalgesic mi xtures may F ive minutes after intramuscular administration.
be found in Chapter 7 and in the specifie chapters on
anaesthetic management. Duration

Proprietary neuroleptanalgesic 60-90 minutes


combinations Full recovery ta kes up to 2 hours .

Advantages Use of etorphine hydrochloride and


methotrimeprazine in small a nimais
Ease of administration may be considered an Atropine may be given to counteract bradycardia,
advantage although this may precipitate cardiac arrhythmias,
Potential for administration of an antagonist. particularly if supplerriental oxygen is not being ad-
ministered.
Disadvantages There is a considerable degree of ris k associated
with its use in elderly dogs and in debilitated or sick
The narcotic component of sorne combinations animais .
produces such marked respiratory depression Not recommended for use.
Intravenous Anaesthetics 97

Fluanisone/fentanyl citrate FURTHER READING


This combination includes the butyrophenone tran-
Andress JL, Day TK and Day DG ( 1995) The effects of consecutive day
quillizer fluanisone, 10 mg/ml, and the potent opioid, propofol anesthesia on feline red blood cells. Veterinary Surgery
fentanyl citrate, 0 .315 mg/ml. lt is licensed for use in 24, 277-282
rats, rab bits, guinea pigs and mice. It is not licensed for Brearley JC, Kellagher REB and Hall LW ( 1988) Propofo1 anaesthesia
in cats. Joumal of Small Animal Practice 29, 3 15-322
use in dogs. Cullen LK and Jones RS ( 1977) Clinical observations on xylazine/
Further details of its use may be found in Chapter ketamine anaesthesia in the cat. Veterinary Record 101, 115- 116
Hall LW and Chambers JP ( 1987) A clinical trial of propofol infusion
7 and in specifie chapters on anaesthetic management. anaesthesia in dogs. Joumal ofSma/lAnimal Practice 28,623-637
Hall LW and Clarke KW ( 1983) Veterinary Anaesthesia, 8'1' edn.
Baillière Tindall , London
Hall LW, Lagerweij E and Nolan AM (1993) Effects ofmedetomidine
CONCLUSIONS premedication on propofol infusion anaesthesia in dogs. Journal of
Veterinary Anaesthesia 20, 78- 83
Haskins SC, Patz JD and Farver TB ( 1986) Xylazine and xylazine-
Despite seeming to offer the advantages of simplicity, ketamine in dogs. American Journal of Veterinary Research 47,
the use of intravenous anaesthetic agents alone without 636- 64 1
Jones RS (1 979) Injectable anaesthetic agents in the cat: a review.
proper regard for normal good anaesthetic manage- Journal of Sm ali Animal Practice 20, 345 - 352
ment cannet be condoned. It is always vital to ensure Lin HC, Thurmon JC, Benson GJ and Tranquilli WJ (1993) Te lazol
that the airway is open and secure from inhalation of -a review of its pharmaco logy and use in veterinary medicine.
Journal of Veterinary Pharmacology and Therap eutics 16,
foreign material. Hypoventilation and hypoxia must 383-418
be avoided, and equipment for artificial ventilation No lan AM and Reid J ( 1993) Pharmacokinetics of propofol gi ven by
intravenous inf usion in dogs undergoingsurgery. British Journal of
with oxygen must be available. Lack of these basic Anaesthesia 70, 546-551
facilities can no longer be defended. Robertson SA, Johnston Sand Beemsterboer J ( 1992) Cardiopulmonary,
In addition, proper ca re must be ta ken to ensure that anesthetic and postanesthetic effects of intravenous infusions of
propofol in greyhounds and non-greyhounds. American Journal of
hypothermia does not occur, fluid balance is main- Veterinary Research 53, 1027- 1032
tained and that no animal should be discharged from Thurmon JC, Tranquilli WJ and Benson GJ (1996) Lumb and Jones '
Veterinary Anesthesia, 3"1 edn. Williams and Wilkins, Baltimore
the care of a veterinary surgeon until fully recovered Watkins SB, Hall LW and Clarke KW (1987) Propofol as an intravenous
from the effects of anaesthesia. anaesthetic agent in dogs. Veterinary Record 120, 326- 329
CHAPTER NINE - - - - - - - - - - - - - - - - - - -

Inhalant Anaesthetics
John W. Ludders

INTRODUCTION Reaction with metal and carbon dioxide


absorbent
Since their discovery and subsequent use in veterinary Halothane and methoxyflurane rea ct with certain met-
medicine, general anaesthetics have made it possible ais such as aluminium and brass. Thus, anaesthetic
for veterinarians to manage animal patients surgically equipment sho uld be built with alternative materials .
in a manner that is humane and relatively safe. How-
ever, it is the inhalant anaesthetics that have made it Carbon monoxide
possible for veterinary surgeons to extend the bounda- To sorne degree, ali inhalant anaesthetics react with
ries of the surgical sciences. It is these drugs that have soda lime to produce carbon monoxide (CO), but the
enabled veterinarians to anaesthetize animais more magnitude of CO production is greatest with desflurane
safel y and for longer periods of time, thus enabling and enflurane, intermediate with isoflurane and !east
surgical procedures that would have been impossible with haloth ane and sevoflurane (Fang et al., 1995). The
20 years ago. This chapter discusses the inhalant toxicity of CO is weil known, and its accumulation in
anaesthetics in most common use in veterinary medi- breathing circuits should be avoided. This interaction is
cine today. not quantitatively sufficient to preclude the use of
inhalant anaesthetics; however, to reduce the accumu-
lation of CO in circle and to-and-fro systems, inhalant
PHYSICOCHEMICAL PROPERTIES anaesthetics should not be used with dry carbon dio xide
(C0 2) absorbent and thus the absorbent sho uld be
The physical and chemical properties of inhalant an- periodically and regularly replaced with fres h moist
aesthetics determine how and why these drugs are absorbent. Furthermore, since prolonged contact of
used. Figure 9.1 summarizes these properties. These inhalant anaesthetics with absorbent enhances the pro-
anaesthetics are either halogenated hydrocarbons (ha- duction of CO, a system that has not been used fo r
lothane), halogenated ethers (desflurane, enflurane, severa! days, for example over a weekend, should be
isoflurane, methoxyflurane and sevoflurane) or inor- flushed with oxygen before using the breathing circuit.
garric gases (nitrons oxide). Nitrous oxide (N2 0) wi ll
be discussed as a special case at the end of this section. Compound A
Compound A (CF2 =C(CF3)-0-CH2F) is a degradation
Preservatives product that results from the interaction of sevoflurane
Only enflurane, isoflurane and sevoflurane are stable in with C02 absorbent. There is sorne controversy about the
the presence of light and do not require preservatives for toxicity of Compow1d A as it has been shown to produce
storage. Both halothane and methoxyflurane can be renal failure in rats, but not in hu mans or other animais,
degraded by sunlight to toxic end products, and for this including dogs (Bito and Ikeda, 1994; Bito et al., 1997;
reason they are supplied in dark colo ured botties. In Muir and Gadawski, 1998). Baralyme produces a four-
addition, a preservative (0.01% thymol) is added to fold grea ter degradation of sevoflurane va pour to Com-
halothane to increase its stability. As halothane vapor- pound A than does soda lime (Liu et al., 1991). Others
izes within a vaporizer the thymol accumulates as a have concluded that the variability in concentrations of
residue, which can affect the mechanical operation and Compound A found in clinical practice may be due to a
output characteristics of the vaporizer. For example, a number of factors, including fresh gas flow rate and
halothane vaporizer th athas not been cleaned for some degree of rebreathing, sevoflurane concentration and
time may have a turnstile that rotates with difficulty the temperature and dryness of the absorbent (Fang et
mainly due to the sticky nature of the thymol residue. To al., 1996). The effect of dry C02 absorbent on the
ensure proper function, it is recommended that ali production of Compound A seems to be complex- fresh
vaporizers should be periodically cleaned and calibrated but dry absorbent destroys Compound A as it is made
in accordance with the manufacturer's guidelines. while dry absorbentthat has been exposed tosevoflurane
....0
Property Enflurane Halothane lsoflurane Methoxytlurane Desflurane Sevoflurane Nitrous oxide J 0

Fonnula CHFC1-CF-O-CHF2 CBrCIH-CF3 CFr CHCI-O-CF2H CHC12-CF2-0 -CH3 CF3-CHF-O-CF2H CFH2-0-(CF3)2 N20 ~
§
Type of volatile anaesthetic Ether Halogenated hydrocarbon Ether Ether Ether Ether Inorganic gas ~
g,
Molecular weight 184.5 197.4 184.5 165.0 168.0 187.0 44.0 C/)
3
Specifie gravity @ 25°C 1.52 1.86 1.50 1.41 - - - ~

Preservatives Not needed Required Not needed Required Not needed Not needed Not needed ~
§'
Reacts with: "")>
:l
Soda lime No Yes No Yes No Yes No
""~
Ultraviolet light No Yes No Yes - - - s-
~
~.
Metal No Yes No Yes No No - ""
""o.
:l
Boiling point (0 C} 56.5 50.2 48.5 104.7 23.5 - -89
@ 760 rnrnHg ~
""
ciQ
Vapour pressure (rnrnHg) ~
ï;ï
20°C 171.8 244.1 239.5 22.8 681 170 -

22°C 188.6 265.5 26 1.8 25.5 743 - -

24°C 206.6 288.3 285.8 28.4 - - -

Vapour concentration
%saturation @ 20°C 22.6 32.1 31.5 3.0 89.6 22.4 -

%saturation @ 22°C 24.8 34.9 34.4 3.3 97.8 - -

Millilitres of va pour/ml 197.5 227 194.7 206.9 209.7 182.7 -


of liquid @ 20°C
Solubility coefficients:
Blood/gas 2.0 2.5 1.5 15.0 0.42 0.68 0.47
Oit/gas 96.0 224.0 91.0 970.0 18.7 47.0 1.4
Fat/gas 83.0 51.0 45.0 902.0 27.0 48.0 1.08
- - ·· - -

Figure 9.1: Physicochemical properties and some solubility characteristics (solvenrjgas) of volatile anaestlletics.
Adapretlfrom Quaslw ct ;Il. ( 1980) a nd Sœjfey ( /996) witlr permission.
Inhalant Anaesthetics 101

for a period oftime can produce unusually high concen- F=CxDx(l-Z)


trations of Compound A (Fang et al., 1996). Z-C

Vapour pressure and vaporizers where F is flow through the vaporizer, C is clesired
Each inhalant anaesthetic has a unique range of va pour anaesthetic concentration, D is total fresh gas flow
pressures that depend on its temperature (Figure 9.1); and Z is the ratio of anaesthetic vapour pressure to
as temperature increases so does va pour pressure. At a barometric pressure.
comfortable room temperature of 20°C, the range of For example, using a Copper Kettle, an anaesthe-
vapour pressures varies widely, from 23 rrunHg for tist wants to cleliver 1% halothane to a patient and
methoxyflurane to 681 mmHg for desflurane. From wants the total fresh gas flow (D) to be 3 1/min of
this information can be derived the maximum possible oxygen. Barometric pressure is 760 mmHg and the
concentration for a given anaesthetic. For example, at temperature of the liquicl anaesthetic is 20°C (a
20°C and 760 rrunHg (barometric pressure at sea halothane vapour pressure of 244 mmHg). Using
leve!), the maximum concentration of methoxyflurane the above formula, where C = 0 .01, D = 3000 ml/min
is 3% (23/760 x 100) wh ile, under the same conditions and Z = 244/760 = 0.32
of temperature and pressure, desflurane can achieve a
concentration of 89%. Since only fractions of the F = 0.01 x 3000 x (1 - 0.32)
maximum possible concentration of any inhalant an- (0.32- 0.01)
aesthetic are neecled to maintain anaesthesia safely in
a patient, a method is needed to control the delivery of F = 65 .8 ml/min through the vaporizer.
clinically useful concentrations to a patient. Vaporiz-
ers are designed to regulate and control factors that Finally, mental calculations can be used (easy to
influence the vaporization of liquid anaesthetics, and a do with halothane and isoflurane). From the example
number of design characteristics are used to define above the ratio of halothane vapour pressure (at
vaporizers. Other sections in this manual describe 20°C) to barometric pressure is 0.32, or roughly
vaporizers that are uniquely designed and calibrated 33%. This means that about one-thire! of the vaporizer
for specifie anaesthetics. However, there are other output is halothane and two-thircls are the gas deliv-
vaporizers that can volatilize any anaesthetic, but that ered to the vaporizer (in this case oxygen). More
require the anaesthetist to calculate gas flows to deter- specifically, the output from the vaporizer consists
mine the concentration of delivered anaesthetic. of 33 ml of halothane vapour per minute and 66 ml
of oxygen per minute. To clilute the 33 ml of halo-
Measured flow vaporizers thane va pour from 33% to 1% requires a diluent flow
The use of a measurecl flow vaporizer requires that the of about 3000 mlfmin.
anaesthetist know the temperature of the liquid anaes- Another example: if 100 ml of oxygen is cleliverecl
thetic and calculate the carrier and diluting gas flows to a Copper Kettle containing halothane at 20°C, how
needecl to deliver a desiree! concentration of anaes- much diluent gas flow is required to achieve a 1%
thetic to a patient. In the past, when these were the most halothane vapour concentration? The input to the va-
common type of vaporizers, the manufacturers pro- porizer of 100 ml represents two-thirds of the eventual
vided calculators like slide ru les to assist anaesthetists, output. Thus total output will be 150 ml/min of which
but these calculators are no longer made. 50 ml is halothane vapour. To clilute the halothane
Sorne older Foregger anaesthesia machines have a vapour to 1%, about 5000 ml of diluent gas flow will
Vernitrol vaporizer incorporated into the machine, be needed. This approach works just as weil for
which uses a thermal percentage system for deter- isoflurane because it has nearly the same va pour pres-
mining anaesthetic clelivery to the patient. The dilu- sure as halothane.
ent gas flowmeter has two scales: one showing the These mental exercises serve to show why anaes-
gas flow in millilitres per minute and the other show- thetic vaporizers have moved away from the measured
ing temperature in degrees centigrade. The flow- flow design. Although the math is easy, a rniscalcula-
meter controlling gas flow to the vaporizer also has tion (not unlikely under stressful circumstances) can
two scales: one showing gas flow to the vaporizer in be fatal for the patient. Furthermore, the design of these
millilitres per minute and the other showing the older machines and their lack of safety deviees makes
percentage of anaesthetic vapour to be delivered to it possible to turn on the gas flow to the vaporizer
the patient. Vaporizer output is determined by setting without the diluent gas flow and thus deliver very high
the diluent flowmeter to the temperature of the vapor- and potentially lethal concentrations of anaesthetic.
izer and the vaporizer flowmeter to the desired anaes-
thetic vapour concentration. Nitrous oxide
For other measured flow vaporizers, such as the Critical temperature is that temperature above
Copper Kettle or sicle-arm Vernitrol, output can be which the molecules of a substance are too active to
determined by using the formula: be compressed into the liquid state; above critical
102 Manual of Small Animal Anaesthesia and Analgesia

temperature the substance is a gas. Because the boiling off its uptake is reversed and it moves from the blood
point for N2 0 at 760 mmHg is -89°C and its critical to the alveoli . Thus, during the first 5 to 10 minutes
temperature is 36°C, it is a va pour at room temperature after discontinuing the N2 0, the volume moving into
(20°C). At room temperature, N2 0 is provided as a the lung is large and dilutes the oxygen in the alveoli.
liquid in full cylinders under 750 p.s.i. (about 50 This may not be clinically significant in animais with
atmospheres; 5000 kPa). For gases such as oxygen, the adequate pulmonary function or those inhaling high
volume remaining in a cylinder can easily be deter- concentrations of oxygen, but in patients with reduced
mined by loo king at the pressure gauge on the cylin der. pulmonary reserves and breathing air or with addi-
Titis is not the case for N2 0 because the pressure ga uge tiona l dema nds f or oxygen (e.g. shivering), the
will read full as long as there is liquid N 20 remaining dilutional hypoxia can be life threatening. The best
in the cylinder. It is only after ali of the liquid has solution is to keep patients attached to the breath ing
volatilized that the gauge starts to decrease and indi- circuit and to allow them to breathe 100 % oxygen for
cates the amount of vapour left in the cylinder. To the first 5 to 10 minutes after discontinuing N 20.
determine how much liquid N 20 remains in a cylinder,
the full and empty weights of the cylinder must be
known; by subtracting the known empty weight from MAC AND ITS APPLICATION T O
thecurrent weight it is possible to determine how much CLINIC AL PRACTICE
liquid NP remains in the cylinder. Further details may
be fo und in Chapter 4. The term MAC refers to the minimum alveolar con-
Nitrous oxide has some physical characteristics centration of an anaesthetic at one atmosphere that
that distinguish it from other inhalant anaesthetics. It produces immobility in 50 % of subjects exposed to a
has a very low coefficient of solubility in blood, oil and supra maximal noxiousstimulus (Steffey, 1996); bence,
fat, so that its uptake and equilibration throughout the it is a measure of anaesthetic potency. It is also a
body is very rapid. Because it is used in large volumes standard measurement that is applicable to ali inhalant
and its uptake is rapid during the induction phase of anaesthetics and makes it possible to compare equi-
anaesthesia, it enhances the uptake of a second anaes- potent doses of inhaled anaesthetics in terms of their
thetic gas (second gas and concentration effects), espe- effects, and to quantify factors that influence anaes-
cially the more soluble inhalants. Clinically, this means thetic requirements (Figure 9.2). When applying the
that the speed of induction can be enhanced by using concept of MAC to clinical practice it must be kept in
N 20 during induction of anaesthesia with an inhalant, mind that MAC is usually determined in healthy
a feature that is particularly helpful during mask induc- unmedicated animais and that a number of patient-
tions. The down si de of using NP is the phenomenon related factors may increase or decrease M AC (Figure
of dilutional (diffusion) hypoxia. Titis typically occurs 9.3). For example, the M AC of a given inhalant is
at the ti me when the N2 0 is tumed off and the patient reduced by the concomitant use of analgesies (opioids),
is disconnected from the breathing circuit and starts to sedative hypnotics (<X:! agonists) ortranquillizers. Mor-
breathe room air consisting of 20 % oxygen. Nitrons phine administered to dogs redu ces MAC by 17-33%,
oxide, however, is used in large volumes during anaes- depending on the dose used; acepromazine (0.02-0.2
thesia (usually 50 % or greater), and when it is tumed mg/kg i.m.) reduces halothane MAC by about 40%

Species Enflurane Methoxyflurane Halothane Isoflurane Desflurane Sevoflurane Nitrous oxide


Cat 1.2 0.23 1.14 1.63 9.8 2.58 255
Dog 2.06-2.2 0.23 0.87 1.28 7.2 2.1-2.36 188-297
Horse 2.12 2.8 0.88 1.31 7.6 2.31 205
Swine - - 0.91 2.04 10.0 2.66 162-277
Sandhill Crane - - - 1.34 - - -
Duck - - 1.03 1.30 - - -
Rabbit - - 0.82 - 8.9 3.7 -
Monkey (Stump-tailed - - 0.89 - - - 200
macaque)
Rat - 0.27 1.11-1.17 1.38 5.7-7.1 2.45 136-235
Figure 9.2: Minimum alveolar concentrations (MAC) (volume %) for inhalant anaesthetics in selected animais.
Adaptee/from Quaslra et al. ( 1980) a 11d Steffey ( 1996) with permission.
Inhalant Anaesthetics 103

Factors affecting MAC


. Circadian rhythms
. Metabolic acidosis - causes a slight decrease in MAC (methodology affects the results)
. Hypoxia- MACis decreased when Pa02 is below 38 rnmHg
. Anaernia- when oxygen (02 ) content is <4.3 ml OJ lOO ml blood (haematocrit = 13%), MACis decreased
. Hypotension- decreases MAC
. Neurotransrnitter release- increases MAC
. Age - older animais require Jess anaesthetic
. Temperature - increasing temperature increases the cerebral metabolic rate of the brain and increases MAC
. Thyroid function - who le body 0 2 consumption minima ily affects MAC; in dogs, changing from gross
hypothyroidism to gross hyperthyroidism increases MAC by only 20 %
. Electrolytes and osmolality - in general, changes in serum electrolytes or osmolality alter anaesthetic
requirement when they are accompanied by changes in brain sodium concentrations
Lithium - decreases MAC
Calcium - very high cerebrospinal fluid (CSF) calcium ion concentrations produce a state
resembling general anaesthesia
Bromine - decreases MAC
Sodium
Hypernatraemia- increases MAC
Serum and CSF hypo-osmolality dilute CSF sodium and decrease MAC
. Narcotics - decrease MAC
. Sedatives and tranquillizers - decrease MAC
. Local anaesthetics - decrease MAC
. Pregnancy - decreases MAC
. Other inhalant anaesthetics (nitrous oxide) - decrease MAC
Factors NOT affecting MAC
. Type of stimulation
Duration of anaesthesia
. Species- from species to species MAC varies by 10-20 %. Interspecies variation may be explained by
variations in techniques
. Se x
. Hypocarbia and hypercarbia within the range of 14-95 mmHg
. Metabolic alkalosis
. Hypoxia and hyperoxia - within the range of 38- 500 mmHg, oxygen does not affect MAC. Below 38
mmHg, hypoxia induces progressive narcosis and reduces MAC
. Hypertension
. Electrolytes and osmolality
"'
Potassium - no effect
Hyperosmolality - no consistent change in MAC
Figure 9.3: Patient-relatedfactors that do and do not affect minimum aLveolar concentration (MAC).
Reproliucedfrom Quasha ct aL ( / 980) with permission
104 Manual of Small Animal Anaesthesia and Analgesia

pressure and glomerular filtration rate and increases in


Species Halothane AI Isoflura ne AI
the partial pressure of C02 in arterial blood (PaC02 ) .
Dog 2.9 2.51 The degree to which inh alants depress cardiopulmo-
Cat - 2.40 nary function, however, varies from anaesthetic to
anaesthetic, and it is these differences that usually
Horse 2.6 2.33 ouide selection of one inhalant over another.
0

Duck 1.51 1.65


Myocardial contractility .
Figure 9.4: Anaesthettc tndex (Al) fo r !ta lot!ta ne and
A li anaesthetic in halants de press myoca rd1a l
isoflurane in four animal species.
contractility to some degree or another, and it seems
that the mechanism of action is interference with
(Heard et al., 1986); and medetomidine (30 1-1g/kg i.v.) calcium flux and content within the sarcoplasmic re-
reduces isoflurane MAC by 53 % (Ewing et al., 1993) ticulum of myocardial cells. Myocardial contractility
Disease states also affect MAC. In a rodent mode! of is affected most by halothane, then enflurane and least
sepsis, isoflurane MAC was reduced by 57 % (Gill et by isoflurane (Simpson, 1993). Desflurane and
al., 1995). sevofl urane seem to affect contractility in a manner
similar to isoflurane.
Anaesthetic index
The anaesthetic index (AI) is derived by dividing the Systemic vascular resistance
end-tidal concentration of an anaesthetic that produces Isoflurane, desflurane and sevoflurane are more po-
apnoea by the MAC for the anaesthetic (Figure 9.4). tent vasodilators than either halothane or enflurane.
Thus AI is a measure of the tendency for an inhalant The typical cardiac response to vasodilation is an
anaesthetic to cause respiratory depression and ap- increase in heart rate, and this probably explains the
noea. The lower the AI for an anaesthetic, the grea ter higher heart rate observed with isoflurane compared
is its depressant effect on ventilation. with halothane.
MAC and N2 0
Car·diac arrhythmias
The MAC for N2 0 in the dog and cat ranges between
The threshold for adrenaline (epinephrine)-induced
188 % and 297% (see Figure 9.2), whereas its MAC in
cardiac arrhythmias is lower with halothane than with
humans is 105%. Thus the MAC for NP cannot be
enflurane, methoxyflurane or isoflurane. In fact dogs
achieved at normal barometric pressures. Furthermore,
or cats th at develop ventricular premature contractions
N2 0 is not as potent an anaesthetic in animais as it is in
du ring halothane anaesthesia often can be converted to
humans and cannot be used by itselfto produce general
normal sinus rhythm when they are switched to
anaesthesia. However, when N2 0 is used at concentra-
enflurane or isoflurane anaesthesia. Again, in terms of
tions of 50 % to 66 %, theMACofa concomitantly used
the ir arrhythmic effects, both desflura ne and
primary anaesthetic, such as halothane or isoflurane,
sevoflurane seem to be similar to isoflurane.
can be reduced by 20% to 35%. Sin ce these inhalant
anaesthetics depress cardiopulmonary function in a
Pulmonary function
dose-dependent manner, N 20-mediated reduction in
Isoflurane is a more potent respira tory depressant than
MAC can be used to spare cardiopulmonary function .
halothane (see above).
When using anaesthetic gas mixtures that include
N,O, the anaesthetist must make certain that the in-
spired concentration of oxygen is at least 30 %. This is
Hepatic effects
Halothane has been implicated as a causative agent of
easy to do when using relatively high gas flows as ali
hepatitis, but the relationship is multifactorial and
that is required is to make sure that the oxygen flow is
requires other contributing factors such as hypoxia,
30 % or more of the total fresh gas flow. However, if a
drug-induced induction ofhepatic enzymes or immune-
Iow flow closed circuit technique is used, then either
mediated factors. Methoxyflurane and enfl urane, al-
N2 0 should not be used as part of the gas mixture or an
though they have received Jess bad press concerning
oxygen analyser must be used to ensure that the frac-
hepatitis than halothane, have been associated with
tion of inspired oxygen is ~ 30% (see Chapter 4).
anaesthesia-inouced hepatitis . Isoflurane seems to be
much Jess likely to do so, and this may be due to the
PHYSIOLOGICAL EFFECTS OF Jack of toxic metabolites associated with its non-
INHALANT ANAESTHETICS pulmonary metabolism and excretion as weil as to its
low bloodjgas solubility.
Cardiopulmonary effects .
All inhalant anaesthetics, except N 20 , depress cardto- Renal effects
pulmonary function in a dose-dependent manner, as Ali of the inhalant anaesthetics can indirectly affect
shown by decreases in cardiac output, arterial blood renal function by depressing cardiovascular fu nction
Inhalant Anaesthetics 105

and, thus, g lomerular blood flow and fi ltration. In Central nervous system effects
addition, metabolism of the fluorinated ethers (meth- The maj or concerns for properly managing anaesthe-
oxyflurane, isoflurane, sevoflurane and desflurane) s ia in patients w ith intracranial d isease is to prevent
produces fluoride ions as metabolites that ca n cause cl inicall y s ignificant increases in intracranial pres-
rena l tubular damage. However, the rate of metab0- s ure wh ile preserving cerebral perfus ion pressure and
lis m and the concentrations of fluoride ions achieved cerebral blood flow, so that the metabolic needs of the
varies w ith the agent. Following methoxyflurane an- brain are met (see C hapter 20). Halothane, isoflurane,
aesthesia in humans, plasma fluoride concentrations sevoflurane, desflurane and methoxyflurane ali de-
achieved sufficiently hi gh levels to produce renal crease the metabolic rate of the brain (CMR02 ) .
tubular damage and high output rena l fa ilure. How- However, isoflurane and sevofl urane seem to de-
ever, th is phenomenon has not been observed in dogs crease CMR02 more than they decrease cerebral
(Pedersoli, 1977a,b; F leming and Peclersoli, 1980), blood flow, thus preserving a positive o r near no rmal
possibly because the canine ki ciney is more resistant to energy state in the brain . This is not the case for
the effects of fluoride ions than is the human kidney. halothane. Enflurane at increas ing levels of MAC
Studies of the other fluorinated ethers have shown that produces seizures.
the rate of metabolis m is consiclerably less than th at of
methoxyflurane. For example, sevoflurane metabo-
lis m is approximately one-third that of methoxyflu- COST CONSIDERATIONS
rane, and 1.5-2 times that of enflurane, w hile that of
desflurane is minimal (Kharasch, 1996) as is the case The cho ice of which anaesthetic to use in practice is
for isoflurane. Although the canine kidney may be often influenced by cost considerations. The purchase
more res istant to the effects of fluoride ions, it is priee of an anaesthetic is certain! y important, but the
reasonable not to use methoxyflurane fo r a patient with total cost of using a given anaesthetic is a lso deter-
renal d isease. If there is no other option, then recom- mined by the drugs that are used to premedicate
mendations from the human literature s uggest that patients (premedicated patients need lower concen-
methoxyflurane anaesthesia should be limited to no trations of anaesthetics), and the gas fl ows that are
more than 2 MAC hours, i.e. the end-tidal concentra- used. Figure 9.5 compares the cost of halothane w ith
tio n should not exceed MAC (0.23 % in the dog) for isoflurane at three fresh gas flows and two vaporizer
more than 2 ho urs. dia l settings. As can be seen, by using a low flow

Method for calculating millilitres of va pour and millilitres of liquid anaesthetic


millilitres of vapour = (vaporizer dial setting (%) """ 100) x flow to vaporizer (ml/min) x time (min);
millilitres of liquid anaesthetic = millilitres of va pour """ millilitres of va pour/ml of liquid @ 20°C
(see Figure 9. 1)
Anaesthetic Vaporizer Fresh gas Ti me Millilitres Millilitres Cost! (S)
setting (%) flow through (min) ofvapour of liquid (1998)
vaporizer (1/min)
Halothane 2 3 120 7200 31.7 4.43 (1.98)
United Kingdom: 2 1 120 2400 10.6 1.48 (0.63)
J.:34 per 250 ml o r 2 0.14* 120 336 1.5 0.21 (0.09)
!0.14 per ml 1 3 120 3600 15.9 2.23 (0.95)
United States: 1 1 120 1200 5.3 0.74 (0.3 1)
$ 15 per 250 ml or
$0.0 6 per ml
Isoflurane 2 3 120 7200 37.0 17.76 (16.65)
United Kingdom : 2 1 120 2400 12.3 5.98 (5.54)
!119 per 250 ml 2 0.14* 120 336 1.7 0.82 (0.77)
or ! 0.48 per ml 1 3 120 3600 18.5 8.88 (8.33)
United States: 1 1 120 1200 6.2 2.98 (2.79)
$45 per 100 m l or
$0.45 per ml
Figure 9.5: Cost comparison of halothane and isojlurane ar three gas jlows and two vaporizer settings.
• Thi:; j low cou Id be used ifl a lowflow technique (7 m f/kg/min) f or a dog 1\'eig hing 20 kg.
106 Manual of Small Animal Anaesthesia and Analgesia

technique it is possible to reduce the cost of isoflurane and care of anaesthetic equipment, waste anaesthetic
so that it is economically feasible to use it for general gas concentrations can weil exceed NIOSH recom-
anaesthesia. Low flow anaesthesia is discussed in mended maxima. For example, in the studies cited
grea ter detail in Chapter 4. above, halothane concentrations ranged from 0.06 to
37.2 ppm, and N2 0 concentrations ranged from 6 to
270 ppm. In one study (Wingfield et al., 1981) only
ANAESTHETIC POLLUTION AND ITS 13 % of ali machines that were tested were free of
CONTROL leaks. The best way to control waste anaesthetic gases
is to scavenge them, to regularly check and main tain
Numerous studies have clearly shown that chronic anaesthetic delivery equipment and to follow prac-
expos ure to trace anaesthetic gases is a reasonable tices or use techniques that are !east likely to pollute
causative factor for severa] disease entities includ- the work environment. The latter consideration
ing hepatic and renal disease, abortion, infertility strongly suggests that certain anaesthetic techniques
and birth defects, neoplasia and disturbances of the or practices, such as mask or tank inductions, make it
central nervous system (CNS). Recent studies have difficult if not impossible to have a pollution-free
implicated NP as a significant pollutant in the work environment. It also suggests that if mas king
waste anaesthetic gas controversy. It has been asso- and tan king techniques are used, th en it is better to use
ciated with high cancer rates and shown to be them with an anaesthetic that may have fewer health-
fetotoxic, to cause CNS disease, liver di sease and associated side effects, such as isoflurane. Nonethe-
abortion, and to inhibit normal bone marrow func- less, the crucial pointis that it is essen ti alto scavenge
tion. Other causative factors, such as stress and ali anaesthetic gases. Chapter 4 co vers the equipment
expos ure to other agents, certainly must be consid- and techniques for control ling and eliminating waste
ered but, until proved otherwise, it should be as- anaesthetic gases.
sumed that a potential hazard exists with chronic
exposure to trace anaesthetic gases.
REFERENCES
What is meant by ' trace ' concentrations?
Bito H and Ikeda K ( 1994) Closed-circuit anes thesia with s evotluranc
Low concentrations of gas are determined on a vol- in hu mans. Etf ects on renal and hepat ic fun clion and concentrations
ume/volume basis and are expressed as parts per mil- of breakdown products wilh soda lime in thecircuii. Anesrhesiology
lion (ppm); 100% of a gas is 1,000,000 ppm and 1% is 80, 7 1- 76
Bito H, Ike uchi Y and Ikeda K ( 1997) Effects of low-tlow sevotlurane
10,000 ppm. In the United Kingdom, employers have anesthesia on re nal function: comparison with high-tlowsevotlurane
a legal obligation to control anaesthetic gas pollution, anesthes ia and low-tlow isofl urane anesthesia . Anesthesia/ogy 86,
123 1-1237
and this obligation is described in a code of practice Dreesen DW , Joncs G L, Brown J, et al. (1 98 1) Monitoring fo r trace
called Control of Substances Hazardous to Health anesthetic gases in a veterinary teaching hospital. J ournal of the
American Vererinary Medical Association 179, 797- 799
(COSHH). This code requires an employer to protect Ewing KK, Mohammed HO, Scarlett JM, et al. (1993) Reduction of
employees by assessing risk, preventing or control ling isotlurane anaesthetic requirement by medetomidine and its
exposure and installing and maintaining control meas- res toration by ati pamezole in dogs. Americcuz J ournal ofVeterinmy
Research 54, 294- 299
ures with regular examina ti on and testing of the con- Fang ZX, Eger El, Las ter MJ, et al. ( 1995) Carbonmonoxide production
trol measures. In addition, the employer must monitor from degradation of destlurane, entl urane, isotlurane, halothane,
and sevoflurane by soda lime and Baralyme. Anesthesia and
exposure in the work place, provide health surveil- Analgesia 80, 1187- 1193
lance and provide information and training to employ- FangZX, Kandcl L, Lastcr MJ ,et ai. (1 996) Factorsaffecting production
ees regarding hazards that they are likely to encounter of compound A from the interaction of sevotluranc wilh Baralyme
and soda lime. A nesthesia and Analgesia 82, 775- 78 1
in the work place. The code recommends exposure Fleming JT and Pedersoli WM ( 1980) Serum inorganic tluoride and
limits of 10 ppm for halothane, 50 ppm for isoflurane renal fun ction in dogs a ft er methoxytlurane anesthesia, tetracycline
treatme nt, and s urgical mani pulation. Am erican J ournal of
and 100 ppm for N2 0. Veterinary Research 41, 2025- 2029
In the United States, the Nationallnstitute of Occu- Gill R, Martin C, McKinnon T, et ai. (1 995) Sepsis reduccs isotlurane
MAC in a normotcnsive animalmodel ofseps is. CanadianJoumal
pational Safety and Health (NIOSH) has recommended ofAnaesrhesia 42, 63 1-635
that anaesthetic gases in the work place should not Heard DJ, Webb AI and Daniels RT (1986) Effect of acepromazine on
exceed the following concentrations : halogenated the anesthetic rcquireme nt of halothane in the dog. Amet"ican
Journal of Veterinary Researclr 47, 2 113- 2 115
agents, when used alone, 2 ppm; Np, 25 ppm, haloth- Hildebrand SV, Taloff P, Aberg N, eral. (1982) Occupational exposurc
ane and methoxyflurane 0.5 ppm wh en used with N2 0. to waste anesthetic gases in veterinary practice. Califomia
Veterinarian 36, 14- 19
Kharasch ED ( 1996) Metabolis m and toxicity of the ne w anaesthetic
Is there a problem with waste anaesthetic age nts. Acta Anaesrhesiologica Belg ica 47,7-14
gases in veterinary medicine? Liu J, Laste r MJ, Eger E, et ai. ( 199 1) Absorption and degradation of
sevoflurane and is otlurane in a conventional anesthetic circuit.
Severa! studies in North America (Milligan et al., A nesthioiogy and Analgesia 72, 785- 789
1980; Dreesen et al. , 1981; Wingfield et al., 1981; Milligan JE, Sablan JH and Short CE (1980) A s urvey of was te
anesthetic gas concentrations in US Air Force veterinary surgeries.
Hildebrand et al. , 1982; Ward and Byland, 1982) J ournal of the American Veterinaty Medical Association 177,
have clearly shown that without proper scavenging 1021- 1022
Inhalant Anaesthetics 107

Mu ir WWI and Gadawski J ( 1998) Cardiorespiratory effects of law-flow Simpson JI ( 1993) Hemodynantic effects o f the inhalation anesthetic
and closed circuit inhalation anesthesia, using sevotlurane delivered agents. In: Aneslltesia and lhe Pmient witlt Co-existing Heart
with an in-circuit vaporiser and concentrations of compound A. Disease, pp. 13- 26. Little, Brown and Co, Boston
American Journal of Ve1erinary Research 59, 603-608 Steffey EP ( 1996) Inhalation anesthetics. ln: Lumb & Jon es' Veterinary
Pedersoli WM (1977a) Blood serum inorganic tluoride, tetracycline Anes1hesia, 3"1 edn , pp. 297-329. Williams & Wilkins, Baltimore
and methoxytluranc anesthesia in dogs. J ournal of /he American Ward GS and Byland RR ( 1982) Concentration ofhalothane in veterinary
Animal Hospiwl Association 13, 242-246 operating and treatment rooms. Journal ofihe American Veterinary
Pedersoli WM (1977b) Serum tluorideconcentration, renal, and hepatic Medical Associa/ion 180, 174- 177
function test results in dogs with methoxytl urane anesthesia. Wingfield WE, Ruby DL, Buchan RM, et al. (1981) Waste anes-
American Journal of Ve1erinary Researclt 38, 949-953 thetic gas exposures to veterinarians and animal techiticians.
Quasha, Eger and Tin ker ( 1980) Determination and applications of J oumal of 1/te Ameriam Ve1erinary Medical Associa/ion 178,
MAC. Aneslltesiology 53, 3 15-334 399-402
:
1

li

_1 ,
-
CHAPTER TEN

Neuromuscular Blockade
Ronald S. Jones

INTRODUCTION general anaesthetic agents depress central nervous


function to produce narcosis. Unfortunately, at
It has been known for many centuries that, when clin i.cally useful doses they also tend to depress the
hunting for food, South American indians used protective reflexes thai compensate for factors
compounds on the tips of their arrows that coulet such as blood loss. They also depress the cardio-
para lyse anima is . These people showed great vascular and respiratory systems and may affect
perception in developing this hunting technique liver and kidney function. To minimize these un-
and, in particu lar, taking advantage of the fact that toward side-effects it is usual to minimize the dose
curare is not absorbed from the gastrointestinal of general anaesthetic used. Under these circum-
tract. This meant th at animais ki lied by this technique stances it may be necessary to use specifie drugs
coulet be eaten without any problems from the mode to fu lfil the other components of the triad of anaes-
of slaughter. thesia. Neuromuscular blocking agents may be used
The first recorded administration of curare to ani- to provide musck relaxation; their use is discussed
mals was by Sir Benjamin Brody, in 1811. He was also in detail below.
the flrst person to show that artificial ventilation coulet To ensure that reflex depression is adequate
maintain !ife in an animal paralysed by curare. during surgery under anaesthesia using a muscle
The first clinical attempt to use curare in canine relaxant technique, it is usual to give an analgesie
anaesthesia was by Pickett, in 1951. He administered drug as partofthe premedication. In addition, agents
the pure alkaloid, but there were three reasons why that are used to s uppleme nt N 2 0 , eithe r other
his results were unimpressive. First, the preparati.on inhalational agents or opioid analgesie drugs, will
was eructe, second, he did not appreciate that the produce reflex depression.
compound released histamine in the dog and, third,
the dogs were atlowed to breathe spontaneously. The
first report on the use of the depolarizing muscle PHYSIOLOGY OF NEUROMUSCULAR
relaxant, suxamethonium, was by Hall, in 1952. TRANSMISSION
Following the ini tial description of the technique
by Gray and Halton, Gray and another colleague, In orcier to appreciate the action of drugs that act at
Rees, divided general anaesthesia into three com- the neuromuscular junction (NMJ, Figure 10.1), it is
ponents and developed the triad concept. This was essential to be familiar with the physiology of
based on the effects that were required in the patient, neuromuscular transmission. A large myelinated
i.e. narcosis, muscle relaxation and analgesia. Later, nerve from the ventral horn of the spinal corel carries
Gray suggested that the word analgesia was a mis- impulses to the muscle, branching extensively as it
nomer and that the correct term should be ' freedom approaches the muscle. The nerve carries stimuli to
from harmful reflex responses to the trauma of severa! muscle fibres that must be activated simul-
operation' . This was based on the view that as taneous ly to produce a muscle contraction. As the
analgesia means freedom from pain and, as the nerve approaches the muscle cell, its branches !ose
unconscious individual cannot 'feel' pain, it is their myelin sheaths . The nerve terminais lie in
incorrect. It implied that actions such as movement grooves on the surface of the muscle fibre and are
and an increase in heart rate in response to a painful covered by a Schwann cel!. The area where the
stimulus coulet not occur in the unconscious indi- nerve ending lies in close proximity to the muscle
vidual. Reflex depression was, therefore, the pre- fibre is the NMJ. The muscle fibre membrane, which
ferred and more accurate term. forms the groove in which the nerve terminais lie,
Most individual general anaesthetics, when used is deeply corrugated, and these corrugations are
at conventional doses, inadequately fulfil at !east called secondary clefts. Deeper to the secondary
one component of the triad of anaesthesia. Ali clefts is a region rich in mitochondria, which covers
110 Manual of Small Animal Anaesthesia and Analgesia

Vesicles
near Junctional cleft
active zone containing
basement membrane
Axon terminal
Terminal
Schwann
Cholinoceptors in cell
postj unctional

rnernbra:n:e~~~~~~~~~~~~~~.~

Ill
l!J!I

Figure 10.1: Neuromuscular junction. The axon terminal contains mitochondria, microtubules and acetylcholine-containing vesicles.
Reproducedfrom Jones mu/ Payue ( 1988) h'ith permission oftlœ Royal Society of Mt•dicine.

the contractile mechanisms of the muscle. The small MUSCLE RELAXANT DRUGS AND
gap between the nerve terminais and the muscle mem- THEIR PHARMACOLOGY
brane, which is up to 60 nrn wide, is known as the
junctional cleft. Muscle relaxant drugs are of two distinct types : de-
An action potential travelling along the motor polarizing or non-depolarizing (competitive). They
nerve produces depolarization of the nerve terminal are considerably different in their effects.
and triggers the release of acetylcholine, which crosses The non-depolarizing drugs are mainly mono- or
the junctional cleft to s timulate nicotinic biquaternary salts and are very hydrophilic. They do
cholinoceptors on the postsynaptic muscle mem- not produce muscle fasciculations and have a rela-
brane. Acetylcholine is synthesized in the nerve ter- tively slow onset. Their effects are reversible with
minal from choline and acetate in the presence of the anticholinesterases. The relaxed muscle is still respon-
enzyme acetyltransferase. The acetylcholine mol- sive to other stimuli, e.g. electrical stimulation. During
ecules are contained in uniformly sized vesicles, partial paralysis, monitoring of the blockade shows
which are mobilized down the nerve fibre to the fade and post-tetanie facilitation followed by exhaus-
presynaptic membrane where they are concentrated tion and depression of muscle twitch. The effects are
in areas called active zones. The active zones lie potentiated by volatile anaesthetic agents and magne-
directly oppos ite high co nc e ntrations o f sium ions . Repeated bursts of tetanus cause their effect
cholinoceptors, located on the shoulders of the sec- to wear off. Acidosis increases the dura ti on and degree
ondary clefts of the postsynaptic muscle membrane. of non-depolarizing block.
Thus, when the acetylcholine is released, it travels a The depolarizing drugs produce initial muscle
minimal distance across the junctional cleft to reach fasciculations and their action is relatively rapid in
the receptor. Interaction between acetylcholine and onset. Depolarized muscle fibres are unresponsive to
the receptor triggers an end-plate potential, which is other stimuli. Their action is not reversed by
converted to a muscle action potential and then into a anticholinesterases. In partial paralysis, neuromuscu-
muscle f ibre contraction. lar monitoring shows depression of the muscle twitch,
After activating the receptor, acetylcholine is rap- no fade and no post-tetanie facilitation. The effects of
idly hydrolysed by acetylcholinesterase to choline suxamethonium are potentiated by isoflurane, respira-
and acetate. Sorne of the choline is taken up by the tory alkalosis, hypothermia and magnesium ions.
nerve terminal for the resynthesis of acetylcholine. Effects are antagonized by halothane, acidosis and
Neuromuscular Blockade 111

non-depolarizing relaxants. Repeated or continuous ammon ium or steroid compounds. They arediscussed
use will produce either a phase II (non-depolarizing) or in order of their historical discovery .
dual block.
Tubocurarine chloride
Depolarizing muscle relaxants This is the orig ina l non -depolarizing muscle
The only muscle relaxant in this group currently relaxant and is derived from the Chondrodendron
available is suxamethonium (succinylcholine, U.S.P.) tomentosum tree. It is stillused to a variable extent in
chlori de. It is the dicholine ester of succinic acid and humans. As indicated earlier, it does have profound
is hydrolysed by cholinesterase and pseudocholineste- cardiovascular effects in the dog and hence its use
rase to choline and succinic acid. It is not possible to is contraindicated.
predict the sensitiv ity of ani mais to suxamethonium
by measuring the concentration of cholinesterase in Gallamine triethiodide
the blood. As cholinesterase is synthesized in the Gallamine was the first synthetic muscle relaxant to
li ver, however, it is likely that severe liver damage, be produced for clinicat use. It hasan atropine-like
cachexia or malnutrition may prolong the duration effect on the postganglioni c nerve endings of the
of action of the drug. The activity of pseudocholineste- heart, which produces a tachycardia . It may a lso
rase is depressed by organophosphorus compounds block the muscarinic effects of acetylcholine and
(w hic h may be used as ectoparasiticides) and have a direct effect on cardiac P-receptors. It
suxamethonium should not be used in animais that freq uent!y produces a rise in arterial blood pressure
have been recentl y treated with these agents. Admin- and, combined w ith the tachycardia, this may lead
istration of suxamethonium causes transient muscle to greater haemorrhage than normal during surgery.
fasciculations, which are due to initial depolarization The drug should not be used in anima is in which
of the muscle end-plate. It is suggested that the drug renal function is compromised because virtually ali
produces actual muscle injury, which is associated of an admini-stered dose of galla mine is excreted via
with release of potassium into the blood. A rise in the kidneys. However, it has been shown that it is
serum potassium concentration may be associated redistribution, from postjunctional receptor sites
with cardiac irregularities. Prolonged administration to non-specifie tissue acceptors, rather than renal
may, however, produce a large decrease in serum excretion, which limits the duration of action of
potassium concentration. galla mine. A 1 mg/kg dose produces neuromuscular
Administration of suxamethonium may produce an block for -29 minutes.
increase in arterial blood pressure. Variable changes in
pulse rate have been reported. Both bradycardia and Pancuronium bromide
tachycardia have been observed and often the rate will Pancuronium is a biquatemary arnino-steroid, which is
not change. devoid of hormonal acti vity. White up to 30% of an
It has been shown that a single dose of 0.3 mg/kg, adrninistered dose of pancuronium may be metabolized,
when given intravenously to dogs, will have a dura- the rest is excreted as the unchanged parent compound.
tian of action of25-30 minutes to complete recovery. Only 10% is excreted in the bi le and the remainder by the
It has also been suggested that incrementai doses of kidney. Renee, the administration of the compound is
the drug or even infusions may be used. However, contraindicated in animais with impaired renal function,
monitoring of neuromuscular block (see below) is and extreme care is needed in animais with li ver disease.
essenti al in these circumstances, as tachyphylaxis Pancuronium has a minimal effect on the cardiovascular
and so-called phase II (or dual) block may occur. system but it can stimula te the myocardium and produce
With the onset of phase II block, a more prolonged a rise in heart rate and in blood pressure. It shows
return of neuromuscular activity can be expected, relatively little cumulative effect and is readily reversed
but, when it is fully developed, it can be reversed by anticholinesterases. A dose of 0.06 mg/kg has a
by anticholinesterase drugs. There does not seem dura tion of action of -3 1 minutes.
to be any connection between the devel.opment of
tachyphylaxis and phase II block in the dog. It has Vecuronium bromide
also been shown that, when a dose of 0.3 mg/kg of Vecuronium is a steroid agent. It was developed from
s uxamethonium is given to the dog, phase II block pancuronium and differs from it only in the nature of
begins to develop after a single dose but is not f ully the 2 P-atom, which is tertiary as distinct from quater-
developed until after a third or fourth dose. nary. This modification produces a drug molecule that
is significantly different in both physical and chernical
Non-depolarizing muscle relaxants properties. It hasan increaseëi selectivity of pharmaco-
There are a number of drugs in this group but, despite logical profile, shorter ti me course of action and rela-
recent developments in this area, there are only a ti ve lack of cumu lation w hen compared with
few drugs which are worth y of full discussion. Non- pancuronium. It is not sufficiently stable to be supplied
depolarizing muscle relaxants are either quaternary and stored in solution. It is presented in a lyophilized
112 Manual of Small Animal Anaesthesia and Analgesia

form that dissolves readily in water and is stable at metabolized mainly by the Hofmann elimination and
room te mperature for up to 24 hours . Unlike is Jess dependent on plasma esterases than the parent
pancuronium, the drug is not dependent on renal excre- mixture. To date, no information seems to exist on its
tion as its principal route of elimination from the body use under clinical conditions in domestic animais.
and it can, therefore, be used in animais with compro-
mised renal function. The principal route of elimina- Mivacurium
tion wou id seem to be the li ver and, therefore, the drug This is a benzylisoquinoline compound with one
should be used with considerable caution in animais third to ha if the potency of atracurium in primates. In
with impaired hepatic function. Metabolism of the humans, it has a short dura ti on of action because of its
drug is relatively insignificant, as it is primarily elimi- rapid hydrolysis by pseudocholinesterase. Acetyl-
nated in an unchanged form in the bile. cholinesterase metabolism and spontaneous hydroly-
Vecuronium is virtually free from ganglion sis are minimal. It has a relatively slow onset and
blocking activity, and extremely large doses are offset of action in the dog. A dose of 0.03 mg/kg has
required to produce inhi.bition of cardiac muscarinic been used in the dog. It can be reversed by anti-
receptors. Administration of the drug is associated cholinesterase drugs but there is very little published
with minimal cardiovascular effects. Even at high information on its use.
doses, · it has very little effect on heart rate and
arterial blood pressure. It does not seem to release Rocuronium
histamine. It has been shown that, in the absence of This is a monoquatemary steroidal compound of low
halothane, an initial dose of 0 .1 mg/kg has a dura ti on potency, which has a rapid onset of action. The dura-
of action of - 18 minutes. However, under clinical tian of action in equipotent doses is sirnilar to that of
conditions, when halothane was employed as part of atracurium and vecuronium. It has minimal cumula-
the anaesthetic technique, that dose of the drug had tive effects and is potentiated by isoflurane. It has
a duration of action of - 25 minutes. It was also similar cardiovascular effects to vecuronium and is
shown that the drug was non-cumulative and the readily reversible with anticholinesterase drugs.
mean time interval between subsequent increments
of 0.04 mg/kg was 18 minutes. It cana iso be given by Doxacurium
intra-venous infusion at a rate of 0.01 mg/kg/h. This is a very potent, long-acting agent. It is oflimited
potential use in veterinary anaesthesia. Its use has
Atracurium besylate been described in experimental dogs and this has
Atracurium is a novel compound, as it is mainly illustrated the difficulties that are inherent in a relax-
broken down in the plasma by a self-destruction ant with these properties .
process known as the Hofmatm elimination. This
reaction occurs under physiological conditions at· Interaction between depolarizing and non-
body pH and temperature and proceeds independ- depolarizing relaxants
ently from hepatic and renal function. Hence, This is a somewhat complex subject. The effects may
atracurium is the drug of choice in animais with vary from species to species and also with the stage of
impaired function of either the li ver and/or kidneys. block produced by one particular drug wh en the other
As the compound does release histamine under is given.
certain circumstances, it should be used with care ln the dog, it has been shown that prior admini-
in animais with a history of anaphylaxis. Under stration of ali the common non-depolarizing muscle
conditions of clinical anaesthesia in the presence of relaxants s ignificantly reduces the duration of
halothane, a dose of 0.5 mg/kg has a duration of action of suxamethonium. Prior administration of
action of 40 minutes. incrementai doses of 0.2 mg/kg suxamethonium significantly reduces the duration of
are non-cumulative and have a mean duration of action of alcuronium, gallamine and pancuronium .
action of 17.5 minutes. In view of its unique meta- With atracurium, no significant effect is observed but,
bolism and Jack of cumulation, atracurium is an ideal with vecuronium, there is much slower recovery.
drug for giving by infusion . A dose of0.5 mg/kg/h has
been used after an initial bolus dose of 0.5 mg/ kg.
MONITORING OF NEUROMUSCULAR
Cisatracurium besylate BLOCKADE
Atracurium is a mixture of 10 isomers, six of which
were isolated and tested for their pharmacological The monitoring of neuromuscular fonction, during
activity. Cisatracurium is the R-eis, R-eis isomer. It is and after anaesthesia, provides the anaesthetist
considered to be about fi ve times as patent as the parent with valuable information. The data contribute to
compound in most experimental species. It does not improved patient care and a more predictable
produce histamine-like cardiovascular effects or any approach to the use of relaxants, not only during
increase in plasma histamine concentrations. It is routine clinical use but also where the response may
Neuromuscular Blockade 113

be modified by drug treatment, or disease. Monitor- latter conditions the ratio of the amplitude of the
ing also permits detection of partial blockade, when fourth to the first response provides a convenient
redosing and, in the case of non-depolarizing agents, method for assessment of neuromuscular trans-
reversa! are best accomplished. mission. By simply counting the twitches that can be
In humans, attempts were made to assess muscle observed, the extent of the block can be roughly
relaxation in the clinicat situation by observation of assessed and the dose of relaxant adjusted. When
clinicat signs. A number of these techniques have been two or three twitches are visible, redosing may be
applied to the dog but, in general, have not been used to pro long neuromuscular blockade or adminis-
satisfactory, as they require the active cooperation of tration of an anticholinesterase used to reverse non-
the patient. A commonly used method of assessing depolarizing neuromuscular blockaàe. Reversai is
relaxation during anaesthesia is by noting the changes occasionally incomplete or unsuccessful if it is at-
in pressure in the anaesthetic reservoir bag when tempted prior to reappearance of at !east one twitch.
intermittent positive-pressure ventilation (IPPV) is The visual assessment of muscle responses to
being performed. Onset of relaxation is characterized train-of-four stimulation in hu man patients is inaccu-
by an increase in compliance, while return of muscle rate; therefore, in the absence of recording equip-
tone may be detected by a decrease in compliance. The ment, double-burst stimulation is considered to be
method is oflimited value because respiratory obstruc- superior. An initial burst ofthree impulses to the nerve
tion may result in similar pressure changes. In the at a frequency of 50 Hz (one impulse every 20 ms)
clinical situation, small portable nerve stimula tors are followed by a second after an interval of750 ms allows
the on!y useful and effective equipment for assessing visualization or ma nua! detection of small amounts of
neuromuscular blockade. residual neuromuscular block under clinicat condi-
Stimulation of the peroneal nerve in the hindlimb, tions . In the absence of muscle relaxation, two short
or the ulnar nerve in the forelimb, with recording of muscle contractions of equal strength are produced; in
the movement or twitchings of the foot, have been the parti ally paralysed muscle, the second response is
described. A technique of stimulating the facial nerve weaker than the first, i.e. the responses fade. Absence
and recording the movement of the nose has also of fade in response to double-burst stimulation means
been documented. thatclinically significant residual neuromuscular block
A number of different patterns of nerve stimu- is absent.
lation have been described, and the evoked muscle
response depends on the particular pattern chosen. Distinguishing features of neuromuscular
Single twitch stimulation is only considered to be block
useful as a screening test to diffe rentiate between In the presence of partial neuromuscular block, the
central and peripheral apnoea. The height of the mechanical muscle responses to different patterns
evoked twitch produced by a given single stimulus of nerve stimulation display features characteristic
varies over time and with the frequency at which of the type of block present. Responses to single-
the stimulus is applied. Renee, the single twitch twitch stimulation show depression of twitch height
method is not a good indicator of the extent of in ali types of bloc k. However, the degree of train-
neuromuscular blockade. of-four fade, tetanie fade and post-tetanie twitch
Tetanie stimulation, not exceeding a frequency potentiation diffe r in the presence of depolarizing
of 50 Hz, is of value in assessing deep neuromuscu- and non-depolarizing block. The evoked muscle
lar blockade . In this technique, tetanus is applied responses, after initial doses of suxamethonium,
for 5 seconds and the response to post-tetanie stimu- show characteristics of a depolarizing block but,
lation observed. A single tetanie burst of 50 Hz for when high doses are given or its action is prolonged,
5 seconds may a iso be used. If the teta nus is sustained, the characteristics of the block change to resemble
then reversa i of blockade may be cons idered those of a non-depolarizing block. This is known as
adequate. If fade occurs, then a non-depolarizing phase II block. Spontaneous recovery from the
block is present. phase II block takes longer than that from the initial
The train-of-four technique is a suitable technique depolarizing block.
for monitoring neuromuscular block, under clinical The train-of-four ratio has been used to character-
co~ditions , in the dog. Four supramaximal stimuli ize the suxamethonium neuromuscular block in
are applied at a frequency of2 Hz, and each su ch train humans and dogs . Initially, the depolarizing block is
is repeated at an interval of 10 seconds . Absence of indicated by minimal train-of-four fade; however, the
any visible response to the four stimuli characterizes development of phase II block is indicated by marked
complete blockade . Four twitches with equally fade. In the dog, phase II bl~ck begins to develop after
reduced amplitude suggest partial conventional a single dose of 0.3 mg/ kg of suxamethonium. Tachy-
depolarizing blockade. When the four twitches phylaxis, defined as 'a diminishing paralysing action
appea r in order of descending amplitude, this in response to an equivalent dose of relaxant,' is
suggests partial non-polarizing blockade. Under the evident early in the depolarizing phase.
114 Manual of Small Animal Anaesthesia and Analgesia

FACTORS AFFECTING THE ACTION duced by isoflurane and enflurane is somewhat greater
OF RELAXANTS than that produced by halothane. These agents increase
the intensity and du ration of the block via botha central
There are a wide variety of factors that may influence and peripheral action. The peripheral effect is caused by
the action of muscle relaxants. These will, of course, a depressant action on the motor end-plate and depres-
affect thesensitivity to thedrugs and may explainsome sion of acetylcholine release from the motor nerve
of the variation seen in the response to these drugs in terminal. Alteration in muscle blood flow could a Iso be
clinical practice. important, but the inhalational agents do not seem to
affect the pharmacokinetics of the relaxants.
Age
While it is generally accepted that young animais are Antibiotics
sensitive to the old competitive muscle relaxants, they Severa) classes of antibiotics have neuromuscular-
are us ually more res istant to atracurium and blocking properties and severa! mechanisms have been
vecuronium. It is also suggested that they require described. The antibiotics may either have a synergism
larger doses of suxamethonium than older animais. with muscle relaxants or may produce paralysis in their
Elderly animais with some reduction in cardiovascu- own right.
lar, renal and hepatic function are usually more sensi- Aminoglycoside antibiotics, such as streptomycin,
tive to the old non-depolarizing relaxants, whereas old gentamicin and tobramycin, decrease acetylcholine
age seems to have 1ittle effect on the action of atracuri um, release (i.e. have a magnesium-like action) and lower
vecuronium and suxamethonium. post-junctional sensitivity to acetylcholine. The black
is reversed by the administration of calcium, but only
Temperature partially by neostigmine. Calcium may be used
Changes in body temperature affect the response to prophylactically. Polypeptide antibiotics, such as the
muscle relaxants in a complex manner. For example, polymyxins, may decrease acetylcholine release and
hypothermia changes regional blood flow and reduces have a direct effect on muscle. They are very potentin
plasma clearance, renal and biliary excretion and the producing neuromuscular black in the ir own right. The
metabolic rate. The onset of neuromuscular block is block is not reliabl y reve rsed by calcium or
delayed during hypothermia, so that extreme care is 4-aminopyridine, and anticholinesterase administra-
needed to prevent overdosage. The duration of action tion seems to enhance the block. The exact mechanism
is also likely to be increased. Conversely, it has been of the effects of tetracycline antibiotics on muscle
shown th at hyperthermia increases the requirement for relaxants is not known. They have a prej unctional
atracurium in the dog, probably because of an effect on blocking action in addition to an effect on muscle
the Hofmann elimination reaction. contractility. While they chelate calcium, the action is
not thought to be due to a decrease in calcium ions at
Muscle disease the end-plate. Calcium is only partially effective in
Although muscle disease is relatively rare in animais, reversing the black produced by tetracyclines, and
it is weil known that myasthenia gravis occurs in antich::>linesterases have no effect. Lincomycin and
dogs . Dogs with myasthenia gravis are sensitive to clindamycin have a pre- and postjunctional effect.
non-depolarizing muscle relaxants, but it bas been Calcium and anticholinesterases are only partially
shown that both atracurium and vecuronium can be effective reversai agents, and 4-aminopyridine is the
used at one-tenth to one-fifth of the normal dose. drug of choice. Metronidazole wou id not seem to have
Neuromuscular monitoring is essential. Myotonia bas an effect at the NMJ but bas a secondary effect on the
been described in the dog, but there are no recorded distribution and/or metabolism of re laxants .
cases of the use of relaxants in these animais. It is Care should always be exercised when using the
suggested that these animais are likely to be normal in above antibiotics with relaxants, and it should be
their responses to non-depolarizing muscle relaxants emphasized thatrapid absorption ofthese drugs cou id
and sensitive to depolarizing drugs, which tend to occur from the pleural or peritoneal cavities when
provoke a generalized muscle spasm. Animais that they are used intraoperatively. Careful monitoring is
have suffered severe trauma are likely to show resist- essentia l under such circumstances.
ance to the non-depolarizing drugs.
Other drug treatment
Anaesthetic agents A wide variety of other drugs have been shawn to
The majority of injectable anaesthetic agents and NP affect the action of muscle relaxants. A number of
have very little effecton the actions of muscle relaxants. anticholinesterase drugs are known to prolong the
However, ketamine bas been shawn to potentiate some dura ti on of action of suxamethonium. These include a
of the non-depolarizing drugs. It is weil established th at number of organophosphate preparations th at are used
fluorinated inhalational anaesthetic agents potentiate widely as anthelmintics and pesticides in animais and
the non-depolarizing muscle relaxants. The effect pro- are also incorporated into flea collars. Ecothiophate
Neuromuscular Blockade 115

drops, which are used in the treatment of glaucoma, To relax skeletal muscle for easier surgical
ma y a lso pra lo ng the durati on of ac tion of access, during such procedures as laparotomies,
suxamethonium. Anti-arrhythmic drugs and local an- thoracotomies and laminectomies. They are
aesthetics may potentiate both non-depolarizing and also indicated for orthopaedic procedures,
suxamethonium block, due to pre- and postjunctional particularly to facilitate reduction of dislocated
effects. Diuretics that produce a hypokalaemia may j oints. While it has been suggested that the
also potentiate the non-depolarizing relaxants . The reduction of fractured bones may not be
calcium channel blockers, such as verapamil, are being influenced by the use of muscle relaxants,
increasingly used in the treatment of heart disease in clinical experience would s uggest that,
veterinary practice and are reported to potentiate non- particularly in the large breeds of dog, they
depolarizing relaxants and possibly suxamethonium. are extreme ly valuabl e in a number of
orthopaedic procedures
Acid-base balance In the initiation of IPPV. This is not only
The effect of changes in acid- base balance on the essential for intrathoracic surgery but is also
action of relaxants is complex. The effects may be due essential to produce anaesthesia with minimal
to a number of factors, including changes in protein hypercapnia and no hypoxia. Tllis is particularly
bindingand in ionization ofthe drug. The most consist- important in animais with compromised
ent changes are produced by changes in carbon dioxide cardiovascular or respiratory systems undergoing
(C0 2) tensions, either as a respiratory acidosis or relatively major surgery. This enables minimal
alkalosis. Respira tory acidosis pro longs, and alkalosis amounts of anaesthetic agents to be given with
reduces, the effects of atracurium, tubocurarine and maximum effect
vecuronium. However, respira tory acidosis decreases, During delicate procedures, such as intraocular
and alkalosis increases, the effects of gallamine and surgery, so that sudden reflex movements can be
suxamethonium. Pancuronium block is prolonged by prevented
hypercapnia. In view of the complexity of these changes, They may also be employed to provide improved
labora tory studies and predictions may differ from the conditions (including relaxed jaw muscles) for
clinical situation. bronchoscopy and oesophagoscopy
As developments occur in the intensive care of
Electrolyte disturbance animais, Iong-term ventilation in animais with
Hypokalaemia and hypernatraemia may potentiate head or thoracic injuries will increase. This is
the actions of the non-depolarizing drugs, while great! y facilitated by the use of muscle relaxants
hyperkalaemia and hyponatraemia may have the such as atracurium, given by infusion.
oppos ite effect but potentiate suxa methonium
bloc k. Hyper-magnesaemia and hypocalcaemia may
potentiate non-depolari zing re laxants by decreasing CONTRAINDICATIONS
acetylcholine release. Calcium is frequently effec-
tive in antagonizing block associated with muscle Muscle relaxants should never be used in the absence
relaxants and magnesium. of adequate facilities for the provision of IPPV. In
It is ad visable to correct any major electrolyte imbal- practice, this means the availability of endotracheal
ances before using muscle relaxants, but if this is not tubes (ETTs) and anaesthetic equipment and circuitry,
possible, to use them extremely sparingly or not at all. with a rebreathing bag that can be used to provide
manual ventilation. While mechanical ventilators are
Hepatic and renal disease extremely useful, they are certainly not essential. One
The presence ofhepatic and renal disease used to be an of the most important factors in the correct use of
absolute contraindication to the use of muscle relax- muscle relaxants is to appreciate that it is essential to
ants. However, there is considerable evidence to show give anaesthetic agents to ens ure unconsciousness (see
that this does not apply to the use of atracurium, with below). When there are doubts about the ability to
its novel metabolism, which is independent of hepatic assess and ensure unconsciousness during the whole
and renal mechanisms . procedure, then muscle relaxants should not be used.
In addition to the above absolute contraindications,
there are a num ber of other factors th at should be borne
INDICATIONS FOR USE OF MUSCLE in nlind and careful consideration given to them before
RELAXANTS deciding to use muscle relaxants. IPPV increases mean
intrathoracic pressure, redùcing verrous return to the
There are a number of indications for the use of heart. In normal animais, a compensatory reflex in-
relaxants in canine anaesthesia and, as further experi- crease in venous tone occurs. In animais where venous
ence is gained, their use will be widened. Their main tone does not compensate, problems can occur, and
indications are Iisted below: this is particularly important in shocked and hypo-
116 Manual of Small Animal Anaesthesia and Analgesia

volaemic patients. An increase in mean intrathoracic Intermittent positive-pressure ventilation


pressure above atmospheric pressure can cause cardio- Ventilation may be manual or mechanical. For the
vascular fai lure in animais with hypovolaemia. small dog (up to about 10 kg), a Jackson Rees modifi-
cation of the Ayre's T-piece is tJ1e circuit of choice.
The modified Bain circuit can be used in dogs more
CLINICAL USE OF MUSCLE than 10 kg in weight. While the commonly used
RELAXANTS rebreathing circuits, s uch as the Waters to-and-fro and
the circle absorber, have been used for IPPV with
There are a number of general principles that are muscle relaxants, they can pose problems with control
extremely important when muscle relaxants are being of the concentration of co2in the circuit unless end-
used as part of an anaesthetic technique in dogs. tidal C02 can be monitored (Chapter 5). If, however,
Endotracheal intubation, preferably with a cuffed tube, the circle system is used with the absorber out of circuit
is essentia l. This is to ensure a clear airway throughout and with a fairly high fres h gas flow, it is extremely
the who le of the procedure. As the oesophageal muscle useful for controlled ventilation in the dog. In this
re laxes and the protecti ve reflexes of the larynx and system, the absorber is bypassed or the soda lime
pharynx are abolished, the stomach contents are 1ikely removed and ventilation performed.
to be regurgitated and may be inhaled if an ETT is not A number of mechanical ventilators have been
in place. If any means other than an ETT are used to used in dogs weighing more than 10 kg, but one of the
facilitate the administration of anaesthetic gases to an most satisfactory is the Manley, which is a minute
animal, such as a mask, then the stomach and even the volume divider and is operated by the gas flo w
intestines may be inflated by the passage of gas down delivered to it.
the oesophagus by positive pressure applied at the Tidal volumes that have been recommended vary
mouth and/or nose. from 20 to 30 ml/kg and minute volumes from 400 to
It is important to appreciate th at the stated doses of 600 ml/kg. The actual pulmonary ventilation produced
muscle re laxants are only guides to their use, and the by intermittent positive pressure can be monitored by
duration of action and the intensity of block are measuring the end-ti dai C0 2 tension of the patient. In
variable. In view of the many factors that may influ- general, it is recommended that a state of mild hypo-
ence the action of these drugs, it is essentia l to treat capnia should be maintained, i.e. an end-tidal co2
each patient on an individual basis and to monitor concentration of 35-38 mmHg (4.6-5 kPa).
neuromuscular bloc k. Incrementai doses of relaxants If it is not possible to monitor end-tidal C02, a non-
should be about one-tenth to one-fifth of the original rebreathing circuit may be used with relatively high
dose of re laxant. fresh gas flows and co2added to the fresh gas mixture
It is essen ti alto ens ure an 'open vein ' fo r the who le at a concentration of 4 %. It is, therefore, possible to
of the procedure. An intravenous catheter should be utili ze the technique of hyperventilation without the
placed in a cephalic vein before the induction of accompanying deleterious effects of hypocapnia.
anaesthesia. If the animal resents attempts to place the
catheter, anaesthesia should be induced by the intrave- Monitoring of anaesthesia
nous. route using a needle, and the catheter placed as Wh ile a number of the signs that are commonly used
soon as possible after induction. to monitor anaesthesia are abolis hed when muscle
Induction of anaesthesia is normally performed by relaxants are used, it is s till essential to monitor the
the intravenous route. As soon as anaesthesia is in- depth of anaesthesia to prevent the scenario of an
duced and the jaws relaxed, the trachea is intubated ' awake but paralysed ' animal. It is essential that the
with a cuffed ETT and the animal connected to an anaesthetist is fully conversant with the effects of
anaesthetic circuit or ventilator.lt is preferable, at this anaesthetic ageHts during those procedures when
stage, to inflate the lungs with oxygen for three or more re laxants are not employed. Indications th at the depth
breaths. After administration of the muscle relaxant, of anaesthesia during ne uromuscular blockade is in-
IPPV is begun either manually or with a ventilator. A s ufficient include:
carrier gas of 33% oxygen and 66% N2 0 should be
used, although this may be changed to 50:50 during Increases in pulse rate unrelated to haemorrhage,
intrathoracic surgery when Jung collapse may occur or signs of vasovagal syncope (bradycardia with
either accidentally or electively. Low concentrations pallor of the mucous membranes)
of halothane or isoflurane are added to the carrier Dilation of the pupils. Normally the pupils are
gases; the usua l de livered concentration from a cali- constricted at levels of surgical anaesthesia. They
brated vapori zer is in the region of 0.5- 1.5 %, which can dilate again with either increasing or
should be adjusted to meet the requirements of the decreasing depth of anaesthesia
animal. If anaesthesia tends to become light, or analge- Lacrirnation and increased salivation
sia is inadequate, then small incrementai doses of Despite the presence of neuromuscular block,
either fentanyl or alfentanil may be given. twitching of the tongue and of the facial muscles.
Neuromuscular Blockade 117

REVERSAL OF NEUROMUSCULAR It has been reported that the recommended dose of


BLOCK neostigmine and edrophonium can vary widely. This
may be part!y due to a Jack of standardization of the
Reversai of non-depolarizing neuromuscular block is procedures when determining the dose. The dose of
achieved by pharmacological means. The aim is to neostigmine varies from 0.01 to 0 .1 mg/kg and
establish a high concentration of acetylcholine at the edrophonium from 1 to 2 mg/kg. In the clinical situa-
binding site of the post-synaptic cholinoceptors. This tion using the train-of-four response, it is recom-
is achieved by using drugs that inhibit the enzyme mended that at !east two twitches should be present
cholinesterase, thus preventing the breakdown of en- before attempting to reverse the block.
dogenous acetylcholine and allowing its accumulation Before administering the anticholinesterase, an anti-
at the synaptic c le ft to resto re neuromuscular transmis- cholinergic drug such as atropine or glycopyrrolate
sion and normal muscle function. should be given intravenously to black the muscarink
Three drugs have been used for anticholineste- effects of acetylcholine. Doses of 0.04 mg/kg of atro-
rase acti vity : pyridostigmine, edrophonium and neo- pine or 0.01 mg/kg of glycopyrrolate should be used. In
stigmine. However, it is only the last two drugs that sorne centres, these drugs are given at !east 1 minute
have been used extensively in veterinary anaes- before the anticholinesterase, in other institutions they
thetic practice. are given together in the same syringe and adminis-
There are a number of factors that influence tered by slow intravenous injection. Doses of either 0.1
reversai of neuromuscular block, and they should mg/kg of neostigrnine or 1 mg/kg of edrophonium are
be investigated when reversai is considered to be recommended. IPPV should be continued until recov-
incomplete. If the drugs are given during deep ery is adequate. Monitoring of the neuromuscular block
neuromuscular black, as indicated by the absence should be continued until the train-of-fourresponses are
of a response to peripheral nerve stimulation, then ali considered to be of equal force. The reversai drugs are
reversai will be slower. The speed of the reversai given at about 5 minutes before the projected termina-
will also d e pe nd on w hich drug is chosen tian of the procedure. Care is necessary with an exten-
(edrophonium has the most rapid onset) and is sive wound closure and with inexperienced surgeons. If
directly proportional to the dose of reversai agent. an inhalational agent is being given, it is discontinued
lt is likely to be slower in the elderly patient. Respi- once the reversai agents have been given.
ratory acidosis tends to prolong the duration of
action of most non-depolarizing relaxants and impair
reversai by neostigmine. Non-depolarizing black is FURTHER READING
potentiated by either high serum concentrations of
magnesium or by low concentrations of calcium Culien LK ( 1996) Muscle relaxants and neuromuscular block. ln: Lumb
and potassium, and hence blood electrolyte levels and J ones Veterinary Anaesthesia, 3"1 edn, ed. JC Thurmon et al.,
pp. 337-364. Williams and Wilkins, Baltimore
should be checked if there are reversai problems, Hall LW and Clarke LW ( 199 1) Veterinary Anaesthesia, 9" edn.
particularly if the animal is on diuretic treatment. Baillière Tindall, London •
The response to an anticholinesterase can vary con- Jones RM and Payne JP ( 1988) Recent Developments in Muscle
Relaxation: Atracuriw11 in Perspective. Royal SocietyofMedicine,
siderably with the degree ofblock present. In an inves- London
tigation of the reversai of atracurium with neostigmine, Jones RS ( 1992a) Muscle relaxants in canine anaesthesia 1: History and
the dmgs. Journal ofSmall Animal Praclice 33, 371-375
the dose required varied by a factor of 5 when it was Jones RS (1992b) Muscle relaxants in canine anaesthesia 2: Clinkal
given at 10% block as opposed to 50% black. application. Journal of Small Animal Practice 33, 423-429
CHAPTER ELEVEN

Fluid Therapy and Blood Transfusion


Paula F. Moon

INTRODUCTION no fluid shift between compartments. Sodium, the


primary ion present in extracellularfluid (ECF), is also
Fluid therapy is indicated for the treatment or preven- the main component of most electrolyte or crystalloid
tion of decreased oxygen de livery, hypotension, hypo- solutions (see Figure 11.1 ). Sodium freely crosses
volaemia, and electrolyte, metabolic and acid-base capillary boundaries, ta king water with it as it distrib-
disorders. As a patient's health status decreases, the utes throughout the entire ECF volume (ECFV). Simi-
imp01tance of selecting the most compatible fluid larly, ail isotonie electrolyte solutions will distribute
increases. This chapter reviews the decision making themselves throughout the ECFV.
process for designing an appropriate fluid plan for the A solution th at is hypotonie has fewer osmotically
anaesthetized small animal patient. active particles than plasma. Because the addition of
a hypotonie solution decreases the plasma osmotic
pressure, a pressure difference is established between
FLUID DYNAMICS intravascular and extravascular spaces. For equili-
brium to be re-established, water moves out of the
In an emergency, fluids are often administered intrave- intravascular space (low osmotic pressure) and into
nously for the sole purpose of improving blood volume the interstitial s pace and tissue cells (high osmotic
and restoring cardiac output to levels that, at the )east, pressure). Conversely, when a hypertonie solution is
can sustain life. Definitive fluid selection, however, administered, water rn oves from the interstitial s pace
depends on matching the patient's needs with a fluid and tissues (low osmotic pressure) and into the intra-
composition and volume of distribution equivalent to vascular space (h igh osmotic pressure). The more
the deficit. Therefore, it is essential to know the compo- hypertonie the solution, the larger the driving pres-
sition of each solution (Figure 11.1) and how it equili- sure, and the more rapidly the water will move in and
brates within the different fluid compartments of the expand the plasma volume. This is the principal
patient (Figures 11.2 and 11.3). Equilibration of intra- mechanism for the rapid plasma volume expans ion
venous fluid depends on a balance of hydrostatic, after hypertonie saline administration and explains
osmotic and oncotic pressures as we il as the perme- why a smaller volume of hypertonie saline causes
ability characteristics of the capillaries themselves a larger expansion of the plasma volume than an
(Starling's law). Normal vascular endothelium is per- equivalent volume of isotonie saline. Eventually,
meable to small ions or electrolytes but impermeable the shifting water results in no osmotic pressure
to large proteins. Hydrostatic pressure is rarely an difference between compartments, and the volume
important factor in determining the fluid type chosen. of administered electrolyte fluid redistributes evenly
Fluid osmotic and oncotic pressures are more impor- throughout the ECF compartment. He nee, hypertonie
tant criteria when choosing an intravenous fluid. saline is transient in its effect.
Sorne crystalloid solutions consist entirely, or par-
Osmotic pressure tially, of glucose and water. Glucose molecules are
Osmosis is the net movement of water across a semi- unique because they onl y have a transient osmostic
permeable membrane caused by the concentration effect. Because 5% dextrose in water is isotonie and
differences of impermeable solutes . Osmotic pressure- 10% dextrose in water is hypertonie, they produce
the pressure exerted by the partie les within the solution initial shifts in water between the ECF and plasma as
- prevents the movement of water ac ross the membrane. predicted based on osmotic pressures. However, cellu-
Toni city refers to the osmotic pressure of a fluid when lar transport and metabolismrapidly redu ce the amount
compared with plasma. An isotonie solution has the of osmotically active glucose. Consequently, 5 % dex-
same proportion of partiel es and water as that fou nd in trose in water is ultimately hypotonie and should only
plasma. Therefore, isotonie fluid administration pro- be administered to provide free water throughout ali
duces no change in the osmotic pressure of plasma and fluid compartments. Hypotonie solutions, including
Solution Colloid oncotic Osmolarity pH Sodium C hloride Potassium Calcium Magnesium Buffer
...
N
0
pressure (mmHg) (mOsm/1) (mmol/1) (mmol/1) (mmol/1) (mmol/1) (mmol/1) (mmol/1)
~
Isotonie crystalloids "'c:
::l

0.9% Saline (NaCI) 0 308 5.0- 5.7 154 154 0 0 0 0 ~


...,
0
5 % Dextrose in water 0 252-278 4.0-6.5 0 0 0 0 0 0 tl)

Isolyte-S* 0 295 7.4 141 98 5 0 3 29 Acetate/23 gluconate 3


~

Lactated Ringer 's solutiont 0 273 6.5 130 109 4 3 0 28 Lactate :>
::l
Plasma-Lyte:j: 148 0 294-3 10 7.4 140 98 5 0 3 27 Acetate/23 gluconate êï
~
Ringer's solution 0 310 5.8-6.1 147 156 4 4.5 0 0 :>
::l
Hypertonie crystalloids
"'g.
~
3% NaCI 0 1026 5.0 513 513 0 0 0 0
~
7.5% NaCl 0 2567 5.0- 5.7 1283 1283 0 0 0 0 ;·
5% Dextrose in water/ 0 495- 527 4-6 130 109 4 2.7 0 28 Lactate "'::l0-
lactated Ringer's solution
5"
Iso-oncotic colloids "'
ciQ
3% Plasmagel No data 310 No data 120 147 0 Some 0 Sorne ~

6% Albumin 30 310 5.5 154 154 0 0 0 0
6% Hetastarch§ 31 310 5.5 154 154 0 0 0 0
6% PentastacMI 25 310 5.5 154 154 0 0 0 0
Haemaccel** 25-29 No data 7.3 145 145 5.1 6.25 No data No data
Oxypolygelatintt 45-47 200 7.4 145 lOO 0 1 0 30 Carbonate
Hyperoncotie colloids· (in nor mal saline)
6% Dextran 70t 75 309 5.0 154 154 0 0 0 0
10% Dextran 40:j::j: >100 3 10 3.5-7.0 154 154 0 0 0 0
10% Hydroxyethyl starch > lOO 308 Acidic 154 154 0 0 0 0
(RES)§§
20 % RES >100 3 10 Acidic 154 154 0 0 0 0
Hypertonic-hyperoncotic
7.5% NaCl-20% RES >lOO 2567 Acidic 1283 1283 0 0 0 0
7.5% NaCI-6% dextran 70 75 2567 - 4- 5 1283 1283 0 0 0 0
Figure 11.1: Electrolyte composition and pllysical properties of commonly available fluids.
•McGrnw. ln•ù!e, CA. USA . t Baxter 1/ea/rhcare. Deerfield. IL. USA. tTrm'l'twl Labs. Deerfield. IL. USA. §D1t Potll Plwrmacewicals. Wilmin~~ton. DE. USA and Du Pom. SU!,·enage. UK. fOu Pmu Crilical Care, Waukegtt11. IL, USA. **Hoechsr Rous.\·c•l Veterinary , Mi/IOn Keynes, UK.
ttMarslw/lton Veterùwry Croup. West Chesrer. PA, USA liA Iso awuïable itr dextrose: Cambridge Lltbormorù•s, Nc• u·castle upon Tyne. UK. §§Fresenius Lu/, Runcom . Clwshirc•. UK.
Fluid Therapy and Blood Transfusion 121

Fluid type Examples Volume needed to Distribution Examples of clinical


increase plasma indications
volume by 1litre
Co llo id Starch 1 litre Plasma volume Hypovolaernia,
Gelatin hypotension,
Dextrans normovolaemic
haemodilution,
hypoalbuminaemia
Hypertonie 7.5 % Saline 300ml Immediate Hypovolaernic shock,
crystalloid (Na Cl) plasma volume cerebral oedema
expansion
causing ICFV
reduction
Hypotonie 5% Dextrose 14litres Total body Free water deficit,
crystalloid water hypernatraemia
Isotonie 0.9% NaCI 4 litres ECFV (plasma Dehydration, hypovolaernia,
crystalloid Lactated Ringer's volume and hypotension,
solution ISFV nprmovolaernic
expansion) haemodilution
F igure 11.2: Categories, distribution and clinicat indications for commonly availablefluidsfor intravenousfluid therapy.
ECFV- extracellularfluid volwne; ICFV- intracellular fluid volume; ISFV• irrterstitialjluid rolume.

55-60% bodyweight is
total body water 40% tissue

! 1
!
20'% bodyweight is
40 % bodyweight is d 1tracellular water
intracellular water 4 % is 1
16% is
plasma 1
intestinal flu id
fl uid 1
1

Figure 11.3: Distribution ojjluid compartments. lntracellular fluid includes thefluid within red blood cells, as weil as other
ceils. lnterstitial fluid volume includes fluid in the cerebrospinal fluid, pleural and peritoneal spaces and ocular jluids.

dextrose solutions, do not adequately replace fluid water between the vascular and interstitial spaces. The
!osses under conditions of anaesthesia and surgery, normal colloid oncotic pressure of plasma is 20- 25
because they will cause cellular and interstitial oedema mrnHg and, in most situations, it is assumed that plasma
faster than if an isotonie fluid is used to maintain an oncotie pressure is adequate if the serum albumin con-
equivalent degree of plasma volume expansion. The Gentration is :::::2.5 g/dl and the total protein (TP) concen-
movement of free water into cells may either treat tration is :::::5 g/dl. The contribution that proteins (albumin,
cellular dehydration or produce cellular oedema, de- globulins) make to the total plasma osmotic pressure is
pending on the situation in a given patient. Thus, it is small (around 4 %), but is sufficient to cause an osmotic
imperative to consider the effects of a fluid 's tonicity pressure difference with the interstitial fluid that retains
on the patient's fluid compartments . water preferentia lly in the intravascular space.
A normal capillary is impermeable to molecules
Oncotic pressure with molecular weights >35,000 daltons. Solutions
The second important property in selecting a fluid is its containing these large molecules are cons idered
oncotic pressure. Oncotic pressure - the pressure ex- colloids . Iso-oncotic colloids have the same oncotic
erted by the large molecules that do not cross the pressure as p lasma, and hyperoncotic colloids
capillary membranes - influences the distribution of have a higher oncotic pressure . Hyperoncotic fl uid
122 Manual of Small Animal Anaesthesia and Analgesia

administration will increase plasma oncotic pressure !ar resistance. Hypertonie solutions also improve rni-
and will draw water into the vascular compartment, crocirculatory blood flow because of a reduction in
as will hypertonie saline. However, unlike such endothelial cell size and a lower blood viscosity. For a
crystalloid solutions that are composed of permeable more sustained effect, hypertonie crystalloids can be
particles, colloid molecules cannat cross normal administered with a colloid.
capillary membranes. Therefore, the plasma volume
expansion is maintained for a longer period of Disadvantages
time than after administration of an equivalent Most of the adverse effects of hypertonie saline are
crystalloid solution. transient but can be clinically relevant. The most
important side effects are hypernatraemia, hyper-
chloraemia, hypokalaemia, hyperosmolarity and a
FLUIDTYPES metabolic acidosis. For example, at the standard shock
dose ( 4 ml/kg i.v. over 10 minutes), a hyperchloraernic
Isotonie crystalloids metabolic acidosis can cause a transient decrease of
Isotonie crystalloids (e.g. lactated Ringer's solution) 0.05 units in pH that lasts around 10 minutes. New
are inexpensive methods of expanding both the vascu- hypertonie solutions have attempted to prevent sorne
lar and the interstitial fluid compartments. They are of these s ide effects, and both hypernatraemic-
commonly used to maintain plasma volume in uncom- isochloraemic-acetate solutions and isonatraemic
plicated anaesthetized patients, to replace deficits in hyperchloraemic solutions are being developed.
dehydrated patients, to restore third space !osses and to Because of its hyperosmolarity, hypertonie saline
promote urinary flow. Within 30 to 45 minutes after administered through a small peripheral vein to a
administration, around 75-80% of the administered patient with poor perfusion may result in intravascular
volume has left the plasma volume and has redistrib- haemolysis and haemoglobinuria. Hypertonie saline
uted primarily into the interstitial space. This property also produces haemodilution of ali blood components.
of crystalloids usually prevents sustained improve- Finally, ventricular dysrhythmias can occasionally
ment in plasma volume and haemodynamic param- be observed during fluid administration, and their
eters unless they are adrninistered as a continuous incidence may increase with the severity of the
infusion. Large volumes of isotonie fluids, coupled patient's condition.
with their large volume of redistribution, may promo te The use of hypertonie saline in dehydrated
peripheral and pulmonary oedema. patients or patients with ongoing uncontrolled
blood Joss continues to be a controversial tapie.
Hypertonie crystalloids Certainly, with pre-existing cellular dehydration,
hypertonie saline causes a further decrease in cell
Advantages size, and it is especially important to administer
The overwhelming advantage of hypertonie solu- an isotonie crystalloid promptly to replace this
tions is their patent plasma volume expansion (see aggravated cellular fluid deficit. However, sorne
above), and therefore they are useful in the initial evidence suggests that mild cellular dehydration
treatment of hypovolaemic shock by rapid adminis- does not compromise the efficacy of a single dose of
tration of only a small volume of fluid. Replacement hypertonie saline for treatment of hypovolaemia.
of a quarter to one-third of the !ost volume of blood Cardiovascular improve ment is not s ustained,
with hypertonie solution rapidly restores cardio- however, with a second dose of hypertonie saline in
vascular variables compared with three to four these patients. In more severely dehydrated patients,
times the !ost volume that is necessary with isotonie mortality may actually increase with the use of
crystalloids. Hypertonie solutions are a stop-gap hypertonie saline.
therapy and must be followed by the administration The other concern with hypertonie saline is that
of appropriate follow-up fluids (crystalloids, colloids uncontrolled bleeding will worsen (due to the rapid
or blood products). In addition to the treatment of increase in blood pressure) and the likelihood of
shock, slow infusions of hypertonie saline have been mortality may increase. This issue is still being
advocated for intraoperative use during cardiac sur- debated, with data supporting both views. As with
gery, to prevent tissue oedema from conventional any fluid therapy, aggressive volume restoration to
fluid therapy. Hypertonie saline (3-5 %) also de- normotension can promote continued blood loss if
creases intracranial pressure and total brain water in the source of the haemorrhage is not controlled.
experimental traumatic brain injury models, and it Therefo re, it seems rational to provide only enough
may be useful in treating cerebral oedema. fluid to prevent tissue ischaemia and maintain !ife
Hypertonie solutions rapidly expand the plasma support as an initial measure. 1t must be realized that
volume, increase cardiac output and improve blood striving for a normal blood pressure in su ch situations
pressure. Hypertonie saline may directly increase may not be an appropriate end point un til the bleeding
myocardial contractility and decrease systernic vascu- has been controlled.
Fluid Therapy and Blood Transfusion 123

Synthetic colloid solutions be about 0.033 % overall. This incidence is small


In d icati o ns fo r colloid ad min istrat io n a re compared with the extent of reactions after administra-
hypoalbuminaemia, blood Joss, hypovolaemia, third tion of blood, penicillin, barbiturates or contrast me-
space fluid accumulation, sepsis and persistent hypo- dia. The incidence in veterinar y medicine is unknown,
tension. Colloids do not cross normal capillary walls although adverse reactions to dextrans have been re-
and have a more sustained effect on plasma volume ported in both dogs (rarely) and rats (commonly).
than crysta lloid solutions. Compared with plasma, Reactions are usually inlfnediate, after administration
synthetic colloids have a longer storage ti me and there of even a small volume. Therefore, initial slow admin-
is no risk of transmission of infectious diseases and no istration with careful monitoring is justified. Signs of
long-term sensitization effect. Colloids are Jess ex pen- an adverse reaction include hypotension, ischaemia,
sive than plasma, but more costly than crystalloids. flushing, urticaria, respiratory compromise, pulmo-
Ordinarily, the volume of colloid administered nary oedema and gastrointestinal disturbances. In a
should be equa l to, or slightly greater than, the !ost few extremely rare instances, administration of a col-
volume of blood. Compared with isotonie crystal- loid has been fatal.
loids, this translates into less total fluid administered, Although ali colloids affect coagulation, gelatins
Jess fluid distributed into extravascular spaces and are the !east detrimental, followed by starches and th en
Jess risk of peripheral oedema. However, both col- dextrans. For dextrans, the effects have been attributed
loids and crystalloids have been associated with to pla telet coating, precipitation of coagulation factors,
pulmonary oedema in patients with permeable increased fibrinolytic activity and decreased func-
capill aries . D iseased capillaries may leak both tional von Willebrand factor. The effect on coagula-
colloids and fluid into the interstitial spa ce wh en gaps tion with dextrans seems to be dose related. The
in the endothe lium become large enough, resulting manufacturer's recommended dose for 6% dextran
in oedema. Colloids that are larger than the gaps, 70 is up to 20 mlf kg the first day and ha if this dose for
however, may impede transport of water and small the following two days. Higher doses may increase
proteins tluough permeable capillaries. Pentastarch, blood viscosity, vascular resistance and afterload. A
in particular, may be useful in plugging leaky capil- rate of 2 mlfkg/h is not associated with bleeding
laries in patients with sepsis, pulmonary dysfunction, problems in humans, white large doses given rapidly
burns and other diseases with increased ca pi llary may cause haemorrhagic diathesis. There are no con-
permeability. trolled data on the maximum safe dose fo r dextrans in
Typica lly, synthetic colloids are categorized as a veterinary medicine. Empirical doses of 5-10 mlfkg/h
type of dextran, gelatin or starch (Figure 11.4). T he have been suggested for the treatment of hypoprotein-
plasma half-life is proportional to the size of the aernia, while doses of 5- 15 ml/kg as a rapid bolus up
molecules. Molecules ::;50,000 da ltons are rapidly to 40-50 mlfkg/h have been suggested for acute hypo-
filtered unchanged by the kidneys, while larger mol- volaernia. One veterinary study (Concannon et al.,
ecules are degraded, metabolized and excreted tmough 1992) reported that at doses of 20 mlf kg over 30 or 60
both renal and gastrointestinal pathways . Diseases mi nutes, there were minima l haemosta tic abnor-
that alter renal function or vascular permeability will malities in clinically normal dogs, but there were
a lter the duration of plasma volume expansion. In enough alterations to suggest dextrans may precipitate
addition, if high doses of the smaller colloids are bleeding in dogs with marginal haemostatic function.
administered to a patient with rena l dysfunction, The coagulation changes that can occur with hetastarch,
renal tu bular obstruction may occur, potentia lly caus- a lthough measurable, are not as pronounced. Hetastarch
ing acute renal failure. s li ghtly pro longs pa rtia l thro mbo pl as tin and
protmombin bleeding times. Clotting factor VIII
Disadvantages function is decreased 25- 50 %, and there is altered
Three potential disadvantages of all synthetic colloids fi brin formation with hetastarch (Conroy et al., 1996).
are circulatory overload, anaphylactic reactions and Since both dextrans and starches have documented
coagulation disorders. Because of slow fluid redistribu- haematologica l effects that are due to more than simple
tion, circula tory overload and haemodilution may occur haemodilution, one should consider avoiding them
if the patient is not properly monitored. Since errors in and us ing a gelatin or plasma in pati ents wi th
fluid loading with colloids have a prolonged effect, the coagulopathies or von Willebrand' s disease or when
volume of colloid used should be carefully titrated and massive blood Joss is expected.
central venous pressure, systernic blood pressure, pul-
monary capillary wedge pressure, and urine output
should be monitored in patients with pulmonary oedema, PRIORITIES IN FLUID THERAPY
congesti ve heart failure or renal failure.
Historicall y, anaphylactic and a naphy lactoid The primary goal in any fluid therapy plan is to maintain
reactions have been reported in humans fo r ali tmee oxygen delivery to, and oxygen consumption by, vital
classes of colloids; the incidence is estimated to organs, thereby sustaining aerobic metabolism. Oxygen
1-'
Colloid Albumin Polygeline Plasmagel Oxypolygelatin Dextran-40 Dextran-70 Hetastarch Pentastarch ~
%solution 5% 3.5% 3% Vetaplasma 10% 6% 6% 10%
Trade name ~
Haemaccel Rheomacrodex Macrodex Hespan Pentaspan §
::::
Category Protein Gelatin Dextran Starch ;::.
0......,
(/)
Substance Polypeptide Polysaccaride Amylopectin 3
(branched polysaccaride) ~
Source Blood Cattle bone Bacteria Maize or sorghum
>
:::1
§"
;::.
Molecular weight 69,000 35,000 35,000 30,000 40,000 70,000 450,000 264,000
(mean (range) (5000-50,000) (10,000- (5600- 100,000) (15,000- 75,000) (20,000- (10,000- (150,000-
>
:::1
~

in Daltons) 100,000) 175,000) 1,000,000) 350,000)* ~

Oncotic pressure 20 25- 29 45- 47 40 40 30- 35 30-40


[
ï;;ï
(mmHg) ~
:::1
o.
% Interstitial 20 50 50 50 0 0 0 0 >
:::1
~
cjQ
% Intravascular 80 50 50 50 100 100 100 100 ~

Plasma half-life >16 2-4 2- 4 2-4 2-6 6-12 >24 3-8
(hours)
Total Very rapid Very rapid Very rapid Very rapid Rapid Protracted Prolonged
elimination
%Adverse Fewest Sorne (0.78) Few (0.2),t common in rats Extremely rare
reactions (in (0.001) (0)
humans, after
1980)
Coagulopathies Rare Reported Reported
Manufacturer Hoechst Marshallton Abbott Cambridge Baxter Fresenius Ltd,
Roussel Veterinary Laboratories, La boratories, HealthCare, Runcorn,
V eterinary, Group, West North Chicago, Newcastle- Deerfield, IL, Cheshire, UK
Milton Keynes, Chester, PA, IL, USA upon-Tyne, UK USA
UK USA
Figure 11.4: Comparison of commonly available collo id solutions.
*A \'erage mo/ecu/ar weighr ofpentastarch is higher them ltetastarclt although weight m 'erage mo/ecu /ar weiglu is lower, i. e. pemasrarch has anarro wer range of medium weight molecules.
flfpretreated with dextran 1.
Fluid Therapy and Blood Transfusion 125

Variable volume can be calculated based on the final distribu-


Normal range
tion of the chosen fluid type: when administering
Arterial haemoglobin >95 whole blood, give a volume equal to the volume
saturation (Sa02 ) (%) deficit; when administering a colloid, give a volume
equal to 1-1 .5 times the volume deficit, and, when
Base deficit (mrnol/1) +2 to -2
administering an isotonie crystalloid, give a volume
Blood lactate (mrnoljl) <2 equal to 3-4 times the volume deficit (Figure 11.6).
Cardiac index (ml/kg/min) 100- 150 After volume restoration, the second priority is
restoration of haemoglobin concentration. However, a
Central venous pressure Awake: -3 to +4 haematocrit, by itself, gives no information about
(cmH2 0) Anaesthetized: 2-7 oxygen delivery or oxygen uptake by the tissues. If it
Gastric intramucosal pH 7.35-7.41 did, then a dehydrated patient with an increased hae-
matocrit would have an increased oxygen delivery,
Heart rate (beats/min) Dog: 70-180 and fluids would not be needed. This rationÇtle
Cat: 145-200 is obviously incorrect, implying that the comrnon
Haematocrit (%) Dog: 37-55 practice of transfusing red blood cells based on a
specifie haematocrit alone has little scientific basis. A
Cat: 25-45
more rational approach to determining if red cell
Mean arterial blood 80-110 transfusions are necessary is to eva luat~ oxygen
pressure (mmHg) delivery variables and look for evidence of inadequate
Mixed venous haemoglobin >65 Ji'0 2 (see Figure 11.5). For example, in situations of
saturation (Sv02) (%) normovolaemic anaemia (following crystalloid fluid
therapy or if the patient has chronic anaemia), a red cell
Oxygen delivery (D0 2) 20-30 transfusion may not be necessary because blood vol-
(ml/kg/min) ume is adequate and a compensatory increase in car-
Oxygen extraction( %) 20- 30 diac output may have occurred. However, red cell
administration may be indicated if oxygen delivery is
Oxygen uptake (~'02 ) 4-10 below normal, if lactate is being produced (suggesting
(ml/kg/min) anaerobie metabolism) or if oxygen extraction is mu ch
Pulmonary artery wedge 3- 9 greater than normal (suggesting tissue oxygen needs
pressure (mmHg) are greater than delivery). A normalization of these
variables and, especially, an increase in oxygen con-
Urine output (mljkg/h) 1-2 sumption after a unit of blood or packed red cells,
Figure 11.5: Normal values of cardiopulm.onary variables should be considered a positive response, and transfu-
used for monitoring fluid therapy. sions should be continued until oxygen consumption is
no longer dependent on haemoglobin content.
Other priorities in fluid therapy include the correc-
delivery is primarily based on cardiac output, arterial tion or prevention of acid-base, electrolyte and meta-
oxygen saturation of haemoglobin and haemoglobin bolic disorders. These are tailored to the individual
content. The determinants of oxygen consumption (V02) patient and can be addressed either by selecting a fluid
are found in the equation: of appropriate pH and electrolyte composition (see
Figure 11.1) or by adding a supplement to the fluid
(Figure 11.7). Chronic abnormalities should be cor-
rected slowly; acute changes more quickly.
whcrc COis cardi ac output, Hb is hacmoglobin concentration and SaO~ and S\101 are ar1erial and
mixcd vcnous oxygcn saturation, rcspect ivcly.
The pH of the comrnon solutions varies greatly, i.e.
sorne are acidifying and others alkalinizing, depending
A V02 that falls below the normal range (Figure 11.5) is on whether or not buffers are added (see Figure 11.1).
evidence of impaired tissue oxygenation. Chloride or lactate, the anions associated with the
In situations such as acute haemorrhage, both sodium and potassium cations in most fluids, can be
cardiac output and total red cell mass decline. Initially, used interchangeably for most patients. When there is
the consequences of low cardiac output far outweigh concern about acidosis, the clinician should select a
the consequences of low red cell mass. Therefore, fluid of the appropriate pH with a metabolizable buffer
treating hypovolaemia is more important than treating (acetate, gluconate or lactaJe).
anaemia, and restoring volume is more important Calcium-freesolutions, such as saline (0.9% Na Cl),
than maintaining haemoglobin concentration. A dog 's Isolyte and Plasmalyte can be administered simultane-
blood volume is 80-90 mljkg and a cat's blood volume ously with blood products. Solutions that contain cal-
is 60-70 mljkg. A rough estimate for determining the cium, such as lactated Ringer' s, cannot be combined
fluid volume needed to restore the patient's blood with blood products as microprecipitates may occur.
126 Manual of Small Animal Anaesthesia and Analgesia

Calculation of fluid volume needed:


1. Calculate the patient's normal blood volume (BV)
2. Estimate the per cent blood Joss, based on clinicat signs and history
3. Calculate the volume deficit, VD = BV x% blood Joss
4. Determine the resuscitation volume, based on
whole blood volume = VD
colloid volume = 1.5 x VD
isotonie crystalloid volume = 4 x VD
Nonnal blood volume (ml/kg): Dog: 80- 90; Cat: 60-70
Normal plasma volume (ml/kg): Dog: 36-57; Cat: 35-53
Shock fluid rates
Isotonie crystalloid fluids: Dog: 80-90 mlfkg/h; Cat: 60-70 mlfkg/h
7.5% Hypertonie saline ± colloid: 4 ml/kg over 10 minutes
Blood replacement
Millilitres of blood to administer = (desired Hb - existing Hb) x (ml/kg BV x recipient kg weight)
donor Hb
Plasma replacement
Millilitres of plasma to administer = (desired TP- existing TP) x (ml/kg PV x recipient kg weight)
donorTP
Cryoprecipitate*
Millilitres of cryoprecipitate to administer =
recipient kg weight x BV (1/kg) x (1-Hct(l/1)) x (desired- current factor level (U/ml))
Factor level in plasma product (U/ml)
Platelet-rich plasma*
Expected 1-hour platelet count (x 109/1) =
Platelet count before Unit platelet count (x109/l) x unit volume x 0.51 t
+
transfusion (x 109/l) recipient kg weight x BV (1/kg)
Figure 11.6: Guide/ines for calculating replacement offluid and blood components.
BV• Biood volume; Hb• haemog/obin; Hct• haematocrit: TP• total prowin
*Adaptedfrom Mmhews KA ( 1996) with the p ermission of LifeLeam. fCorrects fo r spfenic seqm!Strmion of transfu.;:;ed p larelets.

PREANAESTHETIC FLUID Preoperatively, a minimum database of haemat-


CONSIDERATIONS ocrit and concentrations of TP, glucose and urea (or
creatinine) should be assessed, and the patient should
In a healthy adult, the body is composed of 55-60 % be evaluated for signs of dehydration or haemody-
water, divided unequally into cellular (40%) and namic compromise. Clinicat assessment includesevalu-
extracellular (20%) volumes (see Figure 11.3). The ating s kin elasticity, pulse rate and quality, mucous
ECFV can be subdivided into the interstitial fluid membrane colour, capillary refill time, respiratory rate
volume and the plasma volume. · With disease, any and character, temperature of extremities and behav-
combination of fluid compartments may be increased iour and mentation. The ability to assess ECFV is
or decreased, and every attempt should be made to important but often must be estimated based on these
predict the individual patient's needs. An estimate non-specifie clinical signs and abnormalities such as
of the fluids needed should be calculated to replace haemoconcentration, oliguria, azotaemia and acid-
the fluid deficit, provide maintenance fluids and base or electrolyte alterations. A history suggestive of
replace ongoing !osses. In addition, the anaesthetist ECF deficits may include protracted gastrointestinal
should plan to replace fluid lost through additional fosses (vomiting, diarrhoea, bowel obstruction), sep-
evaporative )osses, surgical blood Joss and third sis, trauma or chronic diu retie administration. In sorne
space fluid loss. cases, additional information such as percentage of
Fluid Therapy and Blood Transfusion 127

Supplement Emergency dose Osmolarity pH Composition (mmol/1)


(mOsmfl)
Calcium chloride (10%) 0:05-0.1 ml/kg slowly 2040 5.5-7.5 34 calcium
68 chloride
Calcium gluconate (10%) 0.5-3 mlfkg slowly or 680 6-8.2 465 calcium
60-90 mg/kg/day gluconate (no data)
Dyxtrose (50%) 500 mg/kg diluted, for 2530 4.2 no data
immediate bolus
Magnesium sulphate 0.15-0.30 mmolfkg 4060 5.5-7.0 4.06 magnesium
(1 g/2 ml) over 5 minutes sulphate (no data)
Mannitol (25%) 0.25-3 g/kg diluted 1373 4.5-7.0 no data
and slowly over 30
minutes
Potassium chloride 0.5-1 mmolfkg/h 4000 4-8 2000 potassium
(2 mmolfml) 2000 chloride
Sodium bicarbonate 0.3 x body weight (kg) 2000 7.8 1000 sodium
(8.4%), (1 mmol/ml) x base deficit (mmolfl) 1000 bicarbonate
or 1 mmol/1
immediately
Tromethamine* (0.3 M) Millilitres needed = 380 8.6 300 trometharnine
body weight (kg) x
base deficit (mmol/1)
x (1.1)
Figure 11.7: Fluid intravenous supplements.
•Abbott Ll1bort1tories. North Clric(lgO. IL USA.

mixed venous blood oxygen saturation, blood gas own physiological mechanisms are relied on to control
tensions, buffer or base deficit calculations, blood cellular fluid deficits. Therefore, for most dehydrated
lactate concentrations, urine output and urine specifie patients a balanced isotonie crystalloid is, again, an
gravity will assist in determining adequacy of tissue acceptable fluid choice. If it can be predicted that
perfusion and severity of metabolic abnormalities. massive acute blood Joss might occur, or that the
Whenever time permits, stabilization of the pa- patient may become severely hypotensive, a crystal-
tient's oxygen delivery, pH and e lectrolytes should laid is an acceptable initial fluid choi.ce, provided that
occur in the preoperative period to optimize the pa- colloids and blood products are immediately available
tient's ability to tolerate the subsequent cardiopulmo- to maintain blood volume as soon as indicated during
nary depressant effects of general anaesthesia. In an the procedure. In more chronic progressive types of
emergency, however, adequate oxygen delivery still hypovolaemia, the patient needs restoration of both
must be restored but mild metabolic, electrolyte and blood volume and interstitial fluid volume and will
acid-base disorders can be corrected during the benefit from a combination of both an isot01ùc crystal-
intraoperative and postoperative periods. Treatment laid (to replace the interstitial fluid deficit, maintain
should always be initiated preoperatively for extreme urine output) and a colloid (to main tain plasma vo 1ume).
hyperka laemia (2':8 mmolfl), acidaemia (pH ~7.20) or Septic conditions or severe ischaemic episodes, from
hypoglycaemia (~60 mg/dl, 3.3 mmol/1) . Fluidsshould any cause, can decrease blood volume but increase
be warmed before administration, because cold flu ids cellular and interstitial volumes because of changes in
will promote hypothermia and increase a patient's capillary and cel! membrane permeability and second-
metabolic oxygen demands as they attempt to maintain ary fluid shlfts. Such patients need fluids to support
body temperature. oxygen delivery, but those fluids should be chosen that
For most routine surgical patients, a balanced iso- will mi1ùmize further tissue or organ oedema. With a
tonie crystalloid solution is an appropriate fl uid ad- pre-existing metabolic acidosis or when there is concerti
ministered at a rate of 5-10 ml/kg/h. Dehydration will for a future acidosis, the pH of th.e initial fluid should be
decrease the cellular, interstitial and plasma fluid vol- near that of plasma (see Figure 11.1), and acetate and
umes, and such patients need volume expansion of ali gluconate, whlch are easier to metabolize than lactate,
fluid compartments. Practically, however, the patient' s may be a betterchoice in severely ill patients. In mild to
128 Manual of Small Animal Anaesthesia and Analgesia

moderate metabolic acidosis, efforts should be made to Water requirements include the need to replace
improve the circula ting blood volume and oxygen deliv- gastrointestinal, renal and insensible !osses (e.g. respi-
ery by either increasing the volume of fluid being ratory, cutaneous). Additional fluids are required to
administered or by restoration of erythrocytes to im- replace blood and third space fluid losses and to
prove oxygen content. Stored blood and packed red prevent hypotension from the vasodilation and myo-
cells are extremely acidotic, and fresh whole blood is cardial depression of general anaesthesia.
preferred to prevent a worsening of the acidosis in Even the awake animal is intolerant to acute blood
critical patients. With a life-threatening acidaemia (pH loss, and rapid intervention is essential. In hypovolae-
<7 .2), administration of an alkalinizing solution may be mic shock, the mortality rate is directly related to the
of temporary benefit while the underlying cause is mag nitude and duration of the ischaemic insult (see
being treated. Controversy exists over the usefulness of Chapter 21). Since life-saving compensatory reflexes
sodium bicarbonate, but other buffers, s uch as are obtunded or removed in patients under general
tromethamine, are commercially available and cause anaesthesia, these patients are even more sensitive to
fewersideeffects (see Figure 11.7). A butfershould not a cute blood Joss and hy povolaemia. Furthermore, seem-
be administered through the same catheter as either a ingly small volumes ofblood Joss may not be tolerated
solution containing calcium (e.g. lactated Ringer's) or in sick, debilitated or traumatized patients.
any type of blood product. The goal of fluid therapy after blood loss is to resto re
blood volume, as a first priority, but also to replenish
interstitial fluid deficits that may have occurred due to
INTRAOPERATIVE FLUID compensatory flux into the vascular space. In emer-
CONSIDERATIONS gency situations, restoration of blood volume and car-
diac output will occur with any fluid that re-expands the
The two concerns for intraoperative maintenance flu- plasma volume (crystalloids, colloids or blood prod-
ids are whether or not to administer glucose, and how ucts). However, colloids and crystalloids both flow
much water, sodium and potassium are necessary to faster through the administration system than blood
replace !osses. G lucose has, in the past, been given products because a fluid's flow rate increases as its
perioperatively to decrease protein catabolism and viscosity decreases. R enee, any acellular solution will
prevent hypoglycaemia. This may be a special concern flow faster than whole blood, and who le blood will flow
for diabetic patients, patients with liver disease or faster th an undiluted packed red ceIls. Practically, there-
paediatric patients. However, the stress response that fore, cardiac output is most rapidly restored with col-
results from anaesthesia and surgery produces an anti- loids and !east rapidly restored with packed red cells.
insulin effect, making it difficult to predict the glucose Due to differences in distribution, the volume of crystal-
requirements for an individual patient. Except where loids must be at !east three times greater th an the volume
hypoglycaemia is likely, routinely administering glu- · of colloid infused to have an equivalent effect on cardiac
cose has two disadvantages. First, hyperglycaemia output. In mild to moderate haemorrhage, crystalloids
may occur, causing an osmotic diuresis and dehydra- are beneficiai because this type of fluid a iso replaces the
tion. Second, studies have indicated that hyperglycae- interstitial fluid deficit. In severe haemorrhage, admin-
mia may worsen neurological ischaemia and outcome istering botha colloid and a crystalloid will restore both
after traumatic brain injury. This latter finding may the blood volume and interstitial fluid volume more
have clinicat relevance for critically ill patients as weil. rapidly. In addition, acellularsolutions will decrease the
To prevent hypoglycaemia, a 2.5% dextrose infusion patient's haemoglobin concentration; and mi id haemo-
can be prepared by the addition of 5 ml of 50% dextrose dilution, by decreasing blood viscosity, may improve
to 100 ml of an isotonie crystalloid solution. This microcirculatory blood flow withoutdetrimental effects
allows additional dextrose to be administered without on oxygen delivery. Conventional shock doses of an
the concern of also administering free water. Blood isotonie crystalloid fluid are 90 mlfkg/h for dogs and 60
g lucose concentration should then be re-eva luated and mlfkg/h for cats (i .e. one blood volume in an hour), with
additional g lucose added to the solution if necessary the fluid rate slowed as soon as favourable responses are
(glucose <80-100 mg/dl (4.5-5.7 mmol/1). observed. If the patient remains unstable, then addi-
Sodium and potass ium are two electrolytes that tional fluids such as colloids and blood may be neces-
must be replaced in the perioperative period. To re- sary to maintain intravascularvolume during the critical
place intraoperative fluid !osses, the sodium and potas- period, with fluid rates dictated by the patient's clinical
sium content of the commonly administered fluids are condition. For emergency blood volume expansion,
similar in compos ition to the ECF (see Figure 11.1). hypertonie saline plus à colloid can be life saving. The
Any whole body imbalance in these two electrolytes standard emergency dose is 4 mlfkg i.v. of 7.5% hyper-
caused by such short-term fluid administration is gen- tonie saline in 6% dextran-70 over 10 minutes, followed
erally weil compensated by the kidneys. There are no by conventional fluid therapy. If hypertonie saline is
short-term requirements for other electrolytes except given more rapidly, hypotension due to direct vascular
in instances where severe derangement has occurred. relaxation and vasodilation may occur. This hypoten-
Fluid Therapy and Blood Transfusion 129

sion, in the face of a life-threatening hypovolaemia, can Special conditions


be detrimental and even fatal. If hypertonie saline is
administered more slowly than the shock rate, fluid Cardiac function
shifting will still occur, but the onset may be slower and Patients with decreased cardiac function do not toler-
maximum effect may be obtunded. Lower hypertonie ate excessive fluid administration. Large sodium loads
saline doses may be necessary in patients with cardiac should be avoided. Colloids are an acceptable alterna-
disease to prevent circulatory overload and cardiac tive but must be titrated carefully because over-expan-
failure. The shock colloid dose is 5-20 ml/kg over 30 sion of the plasma volume with colloids will not be
minutes. It should be noted that ali these crystalloid and corrected very quickly.
colloid shock doses are approximate starting doses. The
safe maximum rate or volume that can be administered Oliguria
is undetermined for any fluid. In one study, 8-14% Patients with acute oliguria a Iso need to be monitored
dehydrated butotherwise healthy dogs received lactated carefully, as the oliguria may be renal or prerenal in
Ringer's solution intravenously at a dose of either90 mlf origin. An acceptable plan would be to infuse an
kg/h (group A), 225 mlfkg/h (group B) or 360 mlfkg/h isotonie crystalloid while monitoring urine output,
(group C) for 1 hour (Cornelius et al., 1978). Clinical central venous pressure, blood pressure and heart rate.
signs were absent or mild in groups A and B while group The patient's response to a small fluid challenge may
C showed marked serous nasal discharge, coughing and help differentiate the origin of the oliguria . Signs of
dyspnoea within 20 minutes of fluid administration. It urine output >0.5 mlfkg/h indicate prerenal oliguria. If
may be concluded that isotonie crystalloid fluids prob- a fluid challenge causes neither signs of improvement
ably can be administered faster than 90 ml/kg/h but nor toxicity, and there is concern that further fluids
slower than 360 mlfkg/h in otherwise healthy dogs (i .e. may result in an unacceptable risk, fluid rates should be
no pulmonary oedema, sepsis or heart disease). The rule decreased. In these patients, concurrent therapy may
of thumb is to infuse fluids as slowly as possible but as include dopamine or diuretic administration. If col-
quickly as necessary to produce haemodynamic stabil- loids are chosen, careful titration and monitoring is
ity. While shock doses should be decreased as soon as essential because many colloids are cleared by the
the patient' s clinical condition permits, it is equally kidneys and may have a prolonged effect or worsen the
important to be aggressive during initial resuscitation renal disease.
because dura ti on of ischaemia affects outcome. Cellular
oedema and injury to major organs can continue after Cranial problems
apparent!y successful resuscitation due to the no-reflow Patients with traumatic brain injury and/or increased
phenomenon and reperfusion injury from sustained intracranial pressure are very fragile andres pond quickly
ischaemia. to insufficient or excessive fluid administration. Unfor-
Third spacing is the abnormal accumulation of tunately, no single fluid is superior in this situation, and
fluid in normal extracellular locations. lt is caused by extreme care must be taken in evaluating the patient's
expansion of the interstitial fluid space, ascites, hydra- response. The volume and type of fluid depend on
thorax or fluid accumulation around traumatized tis- whether or not the patient is haemodynamically stable
sues (including excessive surgical manipulation). Loss and if the blood -brain barrier is thought to be intact. The
offluid into these spaces needs to be considered when goal is to provide a systolic blood pressure >90 mmHg
calculating fluid replacement. This fluid loss may lead without detrimentally affecting cerebral perfusion pres-
to hypovolaemia (if the fluid came from the vascula- sure. Paradoxically, cerebral perfusion pressure can
ture), dehydration (if the fluid came from the extracel- decrease with fluid therapy due to the redistribution of
lular space), hypoproteinaemia (if the fluid has high water into the cerebral interstitial and cellular spaces,
protein content) and ultimately, poor tissue perfusion. increasing cerebral oedema and causing secondary brain
The fluid can accumulate in regions that may further injury. The normal blood-brain barrier is relatively
compromise circulation to an organ or within an organ. impermeable to both protein and sodium, causing water
In humans, guidelines for third space fluid !osses are normally to move in or out of brain cells and interstitium
calculated based on extent of expected tissue trauma; in response primarily to capillary osmotic pressure and
these !osses are corrected in addition to the fluids secondarily to oncotic pressure. Therefore, sodium
calculated to replace blood loss. changes are more important than protein changes in
Keeping in mi nd tl1at the greater the tissue damage, these patients. Thus, even a slightly hypotonie solution,
the more the tllird spacing of fluids occurs, estimated such as lactated Ringer's, may promote cerebral oedema.
fluid rates for an anaesthetized patient are approxi- Isotonie saline with supplemental potassium may be a
mately 4 ml/kg/h for procedures with minimal trauma, more appropriate fluid. Ho~ever, prolonged saline use
6 mlfkg/h for moderate trauma, and 8 mlfkg/h for is not advisable because the patient may become
extreme tissue trauma (Giesecke and Egberth, 1985). hypernatraemic or hyperchloraemic, and such a solution
For ali patients, clinical monitoring will determine if is devoid of other important electrolytes. H ypertonic (3-
the rate is adequate or should be adjusted. 5%) saline solution lowers intracranial pressure and
130 Manual of Small Animal Anaesthesia and Analgesia

may decrease cerebral oedema, as weil as provide rapid high-risk surgical patients, survivors frequently had
intravascular volume expansion. Solutions containing supranormal oxygen delivery indices compared with
colloids have been associated with lower intracranial those who Iater died (Eland et al., 1985). Thus, inten-
pressure than with isotonie crystalloid solutions. sive monitoring is necessary in critically ill patients,
Pentastarch, in patticular, is composed of very large even if there are no outward clinical signs of
molecules and may be used to plug Ieaks in the blood- hypoperfusion. The challenge, however, is that there is
brain barrier. Solutions that should be avoided in no practical way to measure oxygen delivery, blood
patients with any type of neurological disease are volume, ECFV, etc. directly and continuously. Both
those containing glucose. It is thought that patients subjective and objective information must be relied
with neurological conditions with increased plasma upon. Subjective signs include lethargy, mu cous mem-
glucose concentrations have a worse neurological brane colour, capillary refill time, temperature of ex-
outcome because the gl ucose promotes cellular tremities and other signs of perfusion. Useful objective
metabolism and leads to anerobic conditions and lactic data include heart rate, direct or indirect arterial pres-
acidosis. In addition, solutions containing only dextrose sure, pulse pressure, central venous pressure, tempera-
cause cerebral oedema due to the free water that remains ture, pulse oximetry, blood pH and gas tensions,
after the dextrose is utilized (see above). If dextrose electrolyte concentration, haematocrit, TP concentra-
must be administered to treat hypoglycaemia, it is tion, urea concentration, urine output and resp~nse to
imperative to add the dextrose to an isotonie solution, fluid challenges, as weil as calculation of oxygen
and not to use dextrose in water. indices (see Figure 11.5).
Many of the common cardiovascular monitoring
techniques have limitations, of which the clinician
POSTOPERATIVE FLUID should be aware. For example, changes in systemic
CONSIDERATIONS blood pressure and heart rate are important but non-
specifie markers of hypovolaemia due to blood Joss.
Most patients receive a high fluid rate preoperatively Hypotension may just as easily be due to excessive
and intraoperati vely to maintain intravascular blood anaesthetic depth, the type of anaesthetic used, cardiac
volume. In the postoperative phase, this fluid may dysfunction or decreases in systemic vascular resist-
redistribute to extravascular spaces thus causing a de- ance. Non-invasive methods fo r measuring blood pres-
crease in intravascular volume, while at the same ti me sure can yield equally low measurements in both
the patient, awakening from anaesthesia, hasan increase hypovolaemic and hypothermie patients (presumably
in blood pressure and glomerular filtration that pro- due to vasoconstrictive responses), and it is difficult to
mates a diuresis. These patients may need additional differentiate between these two, especially when they
fluids for severa) hours after the anaesthetic period to often co-exist in a patient. Cardiac filling pressures,
compensate for this inappropriate diuresis. The diuresis such as central venous pressure and pulmonary artery
may masksigns ofhypovolaemia, as it will seem that the wedge pressure, show a poor correlation to the pres-
patient has adequate urine production. Furthermore, ence and extent of blood Joss until the blood loss is
patients that were not hydrated before anaesthesia may severe (>30 %). Since the values themselves are nor-
continue to be dehydrated at the end of the anaesthetic mall y small and quite variable (i.e. central venous
procedure and continue to require additional fluid vol- pressures of 5-10 cmH20), their usefulness for detect-
ume. On theother hand, interstitial over-expansion may ing significant changes may be limited by the sensitiv-
develop after administration of isotonie crystalloids. ity of the monitoring equipment and the care with
Once haemodynamic stability has returned, this seques- which the transducers are zeroed (see Chapter 5).
tered fluid needs to be mobilized, returned to the plasma Knowing the limitations ofthe various monitoring meth-
volume and eventually removed from the body. Mobi- ods will permit these variables to be useful surveillance
lization of accumulated fluids tends to occur maxima li y tools, as long as ali detected abnormalities are critically
around the third postoperative day, with continued fluid evaluated and investigated further.
sh.ifting fo r up to 10 days, depending on the circum- Periodic assessment of the patient's packed cell
stances and severity of the surgical trauma. Close moni- volume or haematocrit will detect acute anaemia and
toring of haemodynamic variables as weil as urine its direct effect on oxygen delivery. The haematocrit is
output, electrolyte and acid-base status are important often measureq in patients with acute blood loss and
during this period for critically ill patients. during fluid therapy, but it should be remembered that
the haematocrit by itself is not a relia ble or appropriate
method of evaluating blood loss. Since whole blood is
FLUID THERAPY MONITORING )ost during haemorrhage, the haematocrit of the patient
will not change acutely, although the total volume of
The goal of monitoring is to evaluate for adequate blood and red cell mass will decrease. After severa!
oxygen delivery (see Figure 11.5), and to assess the hours, with transcapillary refill and the kidneys ac-
effectof any changes made in the fluid management. In ti ve ly conserving sodium and water, the haematocritof
Fluid Therapy and Blood Transfusion 131

Disorder Fresh Stored Packed Platelet- F r esh C r yoprecipitate Stored or


w hole who le red rich frozen frozen
blood blood celis p lasma plasma plasma
Acute haemorrhage x* x x (plus x (plus x (plus red
colloid) red cells)
celis)
Anaemia x x x*
Coagulopathy x x x* x
H ypoproteinaemia x x*
Platelet function x* x
abnormality
Deficient specifie x* x*
clotting factors
Thrombocytopenia x x*
von Willebrand's x x x x*
disease
Figure 11.8: Indications for blood component therapy.
*Best cltoice ofblood componemfor thal diso rder.

a patient will decrease, but this decrease may not be oxygen extraction >30% is a marker of profound tissue
maximal for up to 24 hours . If, simultaneously, the hypoperfusion, and an oxygen extraction >50 % indi-
patient is treated with asanguineous intravenous fluids cates hypovolaemic shock. Other possible differen-
to promote normovolaemia, the haematocrit will de- tiais for increased oxygen extraction are anaemia and
crease even further as a result of haemodilution of the hypermetabolism. A rough estimate of oxygen extrac-
remaining red cells. Neith er of these causes of decreas- tion can be done using a pulse oximeter (in lieu of an
ing haematocrit are indications of ongoing blood loss. arterial blood gas or arterial haemoximeter) and a
However, a decrease in haematocrit plus a dependeÎlcy mixed venous blood gas in which oxygen saturation
on continued fluid therapy to maintain haemodynamic values are provided. Monitoring blood lactate concen-
stability suggests ongoing blood loss. trations or the base deficit from a blood gas sample will
Even after apparently adequate intravenous fluid provide additional information on the development of
volume replacement, unrecognized tissue hypo- lactic acidosis from hypoperfusion. A lactate concen-
perfusion may be present due to cellular and interstitial tration >4 mmol/1 or a base deficit > -1 0 mmolfl
oedema that developed during the hypovolaemic crisis. suggests profound oxygen debt.
This unseen hypoperfusion is the most likely cause of
many postoperative complications that develop in criti-
cal patients, such as acute renal failure, hepatic failure
BLOOD TRANSFUSION MEDICINE
or systemic inflammatory response syndrome. Moni- The classical indications for blood transfusion are treat-
toring oxygen indices (e.g. oxygen extraction, venous ment or prevention of hypoproteinaemia, hypovolae-
partial pressure of oxygen) is one method of evalua ting mia, coagulation disorders and decreased oxygen del ivery
the adequacy of tissue perfusion. In most situations from acute blood Joss or anaemia. With the increasing
where tissue oxygen delivery falls, tissue oxygen ex- number of commercial animal blood banks in the United
traction will increase as a method of obtaining more States, specifie blood component therapy is possible for
oxygen. The normal Sa02 is >95% and the Sv0 2 > the general practitioner (Figure 11.8).
65%, for a normal extraction of20-30 %. The oxygen
extraction will increase, and Sv02 will decrease, as Blood volume
tissues take out more and more oxygen from the Blood volume is critical for homeostasis. Clearly,
inadequate amount of blood being delivered. At the blood volume will decrease during haemorrhage, but it
point where extraction can no longer increase, oxygen can also decrease with disease associated with hypo-
consumption by the tissues becomes dependent on proteinaemia (due to decreased intravascular oncotic
oxygen delivery (critical oxygen delivery threshold). pressure). Initially, blood volume can be restored with
Experience suggests that the transition from compen- eithercrystalloid or colloid therapy, as described above.
sated hypovolaemia to uncompensated hypovolaemic However, there are two points to consider in deciding
shock takes place when the Sv02 falls below 50% and whether or not blood therapy is indicated: the haemo-
the oxygen extraction approaches 50-60%. Thus, an globin content of the patient and the rate of blood Joss.
132 Manual of Small Animal Anaesthesia and Analgesia

Absolute minimums in haemoglobin content are B lood volume is generally calculated as 8- 10%
controversial fo r both awa ke and anaesthetized pa- bodyweight in dogs (45% cells and 55% plasma), and
tients and should be evaluated in conjunction with around 6% bodyweight in cats (36% cells and 64%
the other determinants of oxygen delivery. Cardiac plasma). Therefore, a given volume of blood !ost will
output and blood flow may increase to compensate be a greater percentage of a cat's blood volume than
for a decrease in haematocrit, but at sorne point that of a dog of the sa me bodyweight. Also, Joss of a
cardiac output and blood flow are maximal and a given volume of blood will have a more profound
lower haematocrit becomes critical. Conventional effect on a smaller animal th an on a larger animal. For
wisdom suggests that a patient can tolerate a lower small patients, counting Q-tips and ga uzes that have
haematocrit when awake or if the anaemi a is of become blood soaked during haemostasis may become
chronic duration. For these patients, a haematocrit essential to assess blood or fluid Joss accurately.
of 18-20% is often well tolerated. However, when
anaesthesia is required, blood products are neces- Blood types and incompatibility reactions
sary sooner because of increased fluid needs du ring A cross-matching test evaluates forserological incom-
s urgery, depressed compensatory reflexes, myocar- patibility between donor and recipient blood, but it
dia l depression and vasodilation from the anaesthet- does not determine blood type. Cross-matching tests
ics. Haematocrits <25-27% may limit oxygen check for the presence of haemolysing or haemagglu-
delivery and delay wound healing. Therefore, de- tinating antibodies in the plasma (or serum) that are
pending on the length of anaesthesia and the inva- directed against red blood cell antigens. Cross match-
s ive ness of th e s urg ica l procedure, th e ing is performed in both dogs and cats to decrease the
pre-anaesthetic haematocrit is recommended to be risk of transfusion reactions, and to decrease the risk of
at !east 30-34% in dogs and 25 - 29% in cats. sensitizing the recipient. Transfusion reactions may
The most common indications for administration occur in previously sensitized animais, animais with
of a blood product during anaesthesia are acute blood naturally occurring isoantibodies or th ose with neonatal
Joss or normovolaemic anaemia from acellular fluid isoerythrolysis. Sensitizing an animal should be avoided
administration. Signs of blood Joss such as tachycar- if more th an one blood transfusion is predicted or if the
dia and hypotension are inconsistent, imprecise and animal is an intact breeding female. Blood typing
unreliable in anaesthetized patients; therapy should reveals blood group antigens on the red blood cell
not be withheld until these signs are observed. Even surface. It is possible to obtain a blood typing card to
in awake healthy patients, a 30-40% acute blood Joss classify dogs as DEA 1.1 positive or negative and
may cause the reflex tachycardia and vasoconstric- another to classify cats as type A or type B.
tion to be !ost, with the sudden and profound onset of
hypotension and hypovolaemic shock. In awake pre- Dog blood types
viously healthy patients, a >40% acute blood loss is About 12 different dog blood types exist (Figure 11.9).
usually fatal unless immediate volume and haemo- The most antigenic is DEA 1.1, followed by DEA 1.2
globin restoration occurs. Under anaesthesia, the and, possibly, DEA 7. In contrast to cats, dogs do not
amount of permissible blood loss is much Jess. An seem to have any clinically important naturally occur-
anaesthetized patient with an acute blood Joss of ring antibodies to other dog blood types. The low
~ 10 % may require a blood transfusion, especially if incidence of DEA 1.1, 1.2 and 7, and the Jack of
the patient also becomes haemodynamically unsta- naturally occurring antibodies, have two important
ble, a pro longed anaesthesia time is predicted or clinicat implications. First, if neither donor nor recipi-
additional blood loss is likely. ent bas ever received a transfusion before, a cross
The actual blood volume of a patient should be match will not detect any alloantibodies even if the
calculated to determine the significance of fluids !ost blood samples are of two different types. Second, a
in the perioperative period as well as to predict the random, first-time transfusion is unlikely to cause an
volume offluid necessary to replace deficits. Calculat- immediate incompatibility reaction because4- 14 da ys
ing the exact blood volume in larger animais is often are required for the recipient to produce antibodies to
overlooked, but it is important to have an estimate. the donor cells.

Blood type (DEA) 1.1 1.2 3 4 5 6 7 8


USA 33- 45 7-24 5-10 87-98 12-25 67- 99 8- 45 40
Netherla nds 38 4 5 56 8 74 31 17
Japan 44 22 24 No data No data 60 No data No data
Figure 11.9: Population incidences (percentages) of canine blood types.
Atlapted f rom Giger et al. ( 1995) Journal oj the Americar1 Veterinary Medica l Assocituion 106(9), J358- 1362, with permission.
Fluid Therapy and Blood Transfusion 133

Domest ic shorthair ca ts* Type A Type B Pu r ebred cats Type A TypeB


( %) ( %) (%) ( %)
USA Northeast 99.7 0.3 Abyssinian 84 16
North Central 99.6 0.4 American Shorthair 100 0
Southeast 98.5 1.5 Birman* 82 18
South west 97.5 2.5 British Shorthair* 64 36
West Coast 95.3 4.7 Burmese 100 0
Other countries Australia (Brisbane) 73.7 26.3 Devon Rex 67 33
Argen tina 97.3 2.7 Exotic Shorthair 73 27
Europe Austria 97.0 3.0 Japanese Bobtail 84 16
England 97.1 2.9 Maine Caon 97 3
Finland 100 0 Norwegian Forest 96 7
France 85.1 14.9 Oriental Shorthair 100 0
Germany 94.0 6.0 Persian 86 14
Italy 88.8 11.2 Scottish Fold* 81 19
Netherlands 96.1 3.9 Siamese 100 0
Scotland 97.1 2.9 Somali* 82 18
Switzerland 99.6 0.4 Sphinx* 83 17
Tonkinese 100 0
Figure 11.10: Blood rype A and B frequency in cats.
Rt produced f rom Giger U a11d Oakley D ( 1998) Currem felin~ transfusion tlterapy: w~ique issues in ems. ln : Proceedings of the Vllmemational Vtterinary Emergency mrd Critical Care
Synwosium, pp. 207-210. h'itlt permission.
• Breeds wilh isolated type AB ems.

For blood transfusions in dogs, it is recommended An acute haemolytic reaction occurs when mis-
that blood donors be confirmed DEA 1. 1, 1.2 and 7 matched blood is admin istered to a previously sensi-
negative (with DEA 1.1 the most important). These tized recipient. The most severe reaction will occur
dogs can be considered universal donors because when a previous ly DEA 1.1 sensitized dog receives
the other blood types cause minimal antigenic another DEA 1.1 blood transfusion. The signs of an
stimulation in unsensitized dogs. It is preferable to acute transfusion reaction are variable and can develop
blood type the recipient as weil, to prevent a delayed within minutes to hours after the transfusion has be-
haemolytic reaction and to prevent sensitization gun. The severity of the signs is roughly proportional
(see below) but, in emergency situations, this can to the amount of incompatible blood received and the
be foregone. Nevertheless, a blood type and cross degree of incompatibility. Common signs include fe-
match should always be performed if either the ver, vomiting, urticaria, haemoglobinaemia and hae-
donor or recipient has previously received a blood moglobinuria. Although rare, the reaction can be fatal,
transfusion. with initial signs of severe hypotension, bradyca rdia
and erratic respirations. If the animal survives this
Incompatibility reactions in dogs phase, a second phase may occur in which the patient
An immediate or delayed reaction can occur with becomes tachypnoeic, hypertensive and tachycardie
incompatible blood types. If a cross match is not and may develop othe r cardiac dys rhythmias .
available and the dogs are of different blood types, the Stabil ization, if it is to occur, generally follows within
recipient dog may destroy the donor red cells as anti- 30 minutes.
bodies develop. This delayed haemolytic transfusion
reaction can be observed as a rapid decline in the Cat blood types
haematocrit a ver 1-2 weeks after the transfusion and is Cats have an AB blood group system: the most corn-
easily overlooked or misdiagnosed on follow up blood mon blood type is type A (Figure 11.10). A and B are
work. The dog also is now sensitized to that blood type, a1leles, with A being dominant. The third cat blood
and ali future transfusions with blood of that type may type, type AB, is inherited separately as a third allele
cause an acute haemolytic reaction. that is recessive to A and co-dominant with B . In
134 Manual of Small Animal Anaesthesia and Analgesia

Packed cell volume of donated blood (including anticoagulant)


Packed cell 30% 32% 34 % 36% 38 % 40% 42% 44% 46 % 48 % 50%
volume of
4% 16.3 15.3 14.4 13.6 12.9 12.3 11.7 11.1 10.6 10.2 9.8
recipient
6% 14.0 13.1 12.4 11.7 11.1 10.5 10.0 9.5 9.1 8.8 8.4
8% 11.7 10.9 10.3 9.7 9.2 8.8 8.3 8.0 7.6 7.3 7 .0
10% 9.3 8.8 8.2 7.8 7.4 7.0 6.7 6.7 6.1 5.8 5.6
12% 7.0 6.6 6.2 5.8 5.5 5.3 5.0 4.8 4.6 4.4 4.2
14% 4.7 4.3 4.1 3.9 3.7 3.5 3.3 3.2 3.0 2.9 2.8
Example: Packed cell volume of recipient 6%
Packed cell volume of donated blood 46 %
Weight of recipient 7 lb
Volume of blood needed per pound 9.1 ml (see above)
Multiplied by weight of recipient x 7lb
Total volume of blood needed = 63.7 ml
Figure 11.11: Volume of blood (millilitres) needed for transfusion per pound (lb) bodyweight of recipient cat basee/ on a
post-tran:;fusion packed cel/ volume of 18% (2.2 lb = 1kg).
Reproducedfrom Norsworrhy GD ( 1977) Ble)()(] rrtmsfusion inrhe cat. Feline Practice 7, 29. u·ith permission

certain breeds, type B can be very common compared type. Type A cats with anti-B serum that receive
with the general population (see Figure 11.10), and mismatched blood will have decreased red cell sur-
historical information from owners or breeders may be vivat (half-life of around 2 days) and a mild, sorne-
important. Thirty five percent of type A cats and 70% times clinically inapparent, transfusion reaction.
of type B cats have natural isoagglutinins against the However, type B cats with anti-A serum that receive
opposite red blood cell antigens. Type AB cats do not type A blood will have tremendously decreased red
have any alloantibodies against either type A or type B cell survival (half-life of around 1 hour) and will
red blood cells. There is no uni versai donor. exhibit marked systemic reactions consistent with
For blood transfusions in cats, it is recommended an acute intravascular haemolytic transfusion reac-
that both donor and recipient cats be blood typed. tion. As little as 5 ml of blood can be fatal in such
Blood typing prevents acute or delayed transfusion situations.
reactions and prevents sensitizing a cat that may not
have naturally occurring alloantibodies. If blood typ- Calculating the transfusion volume needed
ing is not available, a major and minor cross match Formulas have been devised to estimate the volume
should be performed. Small test doses of blood to of who le blood or blood component to administer to
recipient should ne ver be administered. Type A donors a patient (see Figure 11.6). Alternatively, sorne less
are preferred because of their corn mon blood type, but precise rules-of-thumb are available. For whole
access to a type B catis advisable. Cats with type AB blood, a dog can receive 10- 40 ml/kg and a cat 5-20
blood are best transfused with type AB blood or, at the ml/kg, and the patient's haematocrit should be
very )east, type A blood. The reason for not using a type remeasured . However, a volume of who le blood (in
B donor blood is because more type B cats have milli litres) equal to the (required haematocrit rise) x
isoagglutinins than type A cats, and because any (the bodyweight in pounds) can be administered.
anti-A alloantibodies in the type B donor blood wi ll These rough es ti mates are serviceable but do not take
recognize the A antigens in the recipient type AB into account the haematocrit of the donor or the fa ct
blood, causing a more severe haemolytic reaction than that cats and dogs have a different ratio of red cell
using type A donor blood. mass to p lasma volume. A precalculated chart is
also available for cats (Figure 11.11). For plasma, it
Incompatibility reactions in cats can be estimated th at a round 22 ml/kg of plasma will
Because naturally occurring alloantibodies are rouch be necessary to increase albumin concentration by 5
more common in cats than in dogs, a random f irst- g/1. The estimated initial dose of fresh frozen plasma
time blood transfusion will have a higher likelihood for coagulopathies is 10-20 ml/kg bodyweight. This
of a reaction (around 36%) (Kirk and Bistner, 1985). dose may be repeated severa( times to obtain the
The mean survival ha lf- life of feline red cells is desired effect. If cryoprecipitate is needed, the stand-
around 30 days in cats that receive a matched blood ard dose is around 1 ml/kg, or 1 U/10 kg.
Fluid Therapy and Blood Transfusion 135

TRANSFUSION ADMINISTRATION it severa! days to a week before the surgery. Altema-


AND COMPLICATIONS tively, blood can be withdrawn from the patient imme-
diately before the procedure and replaced with
Route of administration appro pria te crystalloids or colloids, a technique termed
J ugular, cephalic and saphenous veins and intraosseous normovolaernic haemodilutio n. This blood can then be
femora l or humera l sites are ali acceptable routes for given when needed intraoperatively without concern of
blood administration. Intraperitoneal transfusions may an incompatible transfusion reactio n. Intraoperativesal-
be ali that is available in neonates, but the rate of vage techniques for autotransfusion have sorne defini te
peritoneal absorption is slow. drawbacks but can be done. Intraoperative salvage is
preferably clone with sorne type of automated cell sa ver
Preparation or blood salvage system. The blood is aspirated from the
Refrigerated blood and blood products should be surgical field, rnixed with anticoagulant and transferred
warmed gently to body temperature before transfusing to a reservoir unit. In the reservoir it is filtered, centri-
(not to exceed 37°C or 98.6°F). Packed red cells can be fuged, washed and resuspended. Complications in elude
di luted with 0.9% saline. Frozen bags of plasma must haemolysis, coagulopathies, decreased calcium and air
be handled carefully to prevent cracking during the embolism. Salvaged blood should not be reinfused ifthe
thawing process. Thawing offrozen plasma, conducted blood may contain tumeur cells, urine, bile, faecal
with a circulating wann water bath with the temperature matter or other contaminants.
between 30 and 37°C (86-98.6°F), generally takes
around 30 minutes. Frozen plasma can be mkrowaved Desmopressin acetate
and be ready to administer after about 3-5 minutes. To Desmopressin acetate (DDAVP) is used to release fac-
microwave frozen plasma, the plasma bag is placed in tor vm and von Willebrand facto r trans iently from a
a container of water, without its sides touching the patient's endothelial stores. It is administered to hu mans
container, and the container is placed in the centre of a with selected types of von Willebrand's disease before
microwave oven (700 W setting). The plasma unit is surgery. The recommencled dose is 0.1-0.3 mg/kg i.v.,
rnicrowaved in 5-10 second periods and is agitated for using human intranasal drops diluted with sterile saline
3- 5 seconds by hand between exposures (to prevent and administered over 10 min utes. The peak effect is
localized overheating). Microwave thawing of canine obtained 30-50 minutes after administration, and the
fresh frozen plasma does not alter the one-stage du ration of response is transient (about 6 hours). In dogs,
prothro mbin time, factor vm coagulant acti vity and a dose of 1-5 mg/kg has been used empirically as an
von Willebrand factor antigen (Hurst etal., 1987). Once alternative to transfusion therapy for sorne patients with
frozen plasma has been thawed in the rnicrowave it von Willebrand's disease, or to increase factor Vill
sho uld be transferred into a water-bath for warming concentrations in the blood donordog 30 minutes before
to body temperature. Thawed plasma should be used collection (Turrentine et al., 1988). Limitations to
within 6-8 hours and should never be refrozen. Liquid DDAVP include its trans ient effect, fai lure of some
plasma and ether components should not be wanned ali dogs to respond (presumably because some dogs have
the way to body temperature in a microwave. inactive or minimal von Willebrand factor, even in
Stored blood and packed red cells become quickly storage) and refractory patients after repeated treat-
acidotic and have higher ammonia concentrations than ments. Thus, DDA VP can only be considered adjunct
fresh whole blood. Citrate-phosphate-dextrose, the therapy in sorne specifie patients and cannat be consid-
anticoagulant solution in most blood collecti.on bags, ered a reliable substitute to transfusion therapy.
has a pH of 5.5. Th us, even the pH of a freshly drawn
bag of blood will decrease to approximately 7.0 or 7.1. Administration and rate
With additiona l storage, lactic and pyruvic ac ids A blood filter must a lways be used to re move
produced by red cell metabolism and glycolysis will microthrombi from blood products. A human adult
accumulate, and the pH may decrease to 6.9 after 3 fi lter is generally acceptable, but when s mall vol-
weeks of storage. A contributing factor to this acidosis umes of blood are being adminis tered, a 170 1-1m
of stored blood is hypercapnia. However, excess carbon micropore filter can also be used safely, with less
dioxide is normally rapidly removed by patients with blood being trapped in the f ilter apparatus.
adequate ventilation. Considering these modifications Al ways administer blood products in a separa te line
of stored blood, fresh who le blood may be more appro- or, at the !east, with compatible fluids that do not conta in
pria te for patients with pre-existing acidosis or hepatic calcium or bicarbonate (e.g. 0.9 % NaCl). Do not adm in-
encephalopathy, or in critically ill patients. ister drugs through the blood line, and do not add any
drugs to the blood bags. Gently oscillate the bag to mix
Autotransfusion the contents periodically during administration.
The best method of autotransfusion is to estimate the An extremely slow rate of administration is ini-
volume ofblood transfusion needed preoperati vely, and tially indicated to observe for signs of an acute trans-
to harvestthis volumeofbloodfrom the patient and store fusion reaction. Even with appropriate serological
136 Manual of Small Animal Anaesthesia and Analgesia

screening, non-immunological transfusion reactions anti bodies reacting to recipient wl1ite blood cell anti-
can occur due to improper storage or transfusion tech- gens may cause white blood cell aggregates or emboli
nique, contamination with infectious organisms, etc. in the recipient's lungs. This may result in pulmonary
As already mentioned, a transfusion reaction can have oedema or hyperthermia and has been termed transfu-
a wide variety of signs but, should any occur, the sion-induced acute Jung injury. Seriai arteri al blood
transfusion has to be aborted immediately. If no trans- gas analysis and pulse oximetry may detect this com-
fusion reaction develops, the subsequent rate should be plication in an anaesthetized patient.
as slow as possible to obtain the desired result over 4- Sorne adverse reactions may not be due to incom-
8 hours. A standard rate of about 4-5 ml/kg/h is patible blood types, but instead to improper handling
generally adequate. If the patient is normovolaemic, or administration of the blood. Dark brown or black
the rate should be slower (2.5-5 mlfkg/h) to prevent blood units should be discarded, as they may be colo-
circula tory overload. In patients with pre-existing car- nized by bacteria, which can lead to sepsis. Bleeding
diac disease, the rate may need to be further decreased can occur if large volumes of factor-free blood compo-
to 0.5-1 ml/kg/h. At the other extreme, 5-15 mlfkg/h nents are administered. In patients affected with
is recommended to treat acutely hypovolaemic ani- coagulopathies, monitoring the platelet number, acti-
mals and, in a life-threatening emergency, rates up to vated clotting time, partial thromboplastin time, pro-
40-60 ml/ kg/h may be required (bolus technique). thrombin time and buccal mucosal bleeding ti me may
be beneficiai. Lung microemboli can cause respira tory
Transfusion monitoring insufficiency if the blood product is not filtered prop-
In this instance, monitoring means evaluating the erly. Circulatory overload can occur ifblood is admin-
response to therapy and looking for signs of acute istered in excess or too rapidly, particularly in patients
transfusion reactions such as a change in attitude, with pre-existing cardiac or renal disease. These pa-
vomiting, pruritus, altered capillary refill time, fever, tients should be monitored for classic signs of vascular
tachycardia, dyspnoea or erratic respirations, periph- overload such as an increase in central verrous pres-
eral oedema, disseminated intravascular coagulation, sure, dyspnoea, vomiting, chemosis or pulmonary
urticaria, hypotension, icterus or haemoglobinaemia. oedema. Citrate toxicity can occur if large vol umes of
B lood pressure, heart rate, body temperature, urine blood areadministered rapid ly and the liver's ability to
output and haematocrit measurements, evaluation of metabolize the compound is transiently overwhelmed.
serum colour and e lectrocardiography are recom- Citrate binds calcium, causing signs of transient hy-
mended to monitor a blood transfusion during anaes- pocalcaerrua with hypotension, a narrow pulse pres-
thesia. Acute haemolysis is s upportive of direct sure and, rarely, cardiac dysrhyth mias. Usually this
incompatibility. If even rruld hypothermia occurs, up complication is self li rruting but calcium supplementa-
to 4- 5 hours after transfusion, the most likely cause is tion may be necessary in sorne cases. Ionized calcium
an incompatibility between the don or white blood ce lis concentrations s hould be measured during trans-
and recipient antigens. For any reaction, treatment fusions of critically ill patients and whenever massive
involves stopping the blood transfusion immediately transfusions are administered rapidly.
and providing supportive care. If the reaction is mild,
the transfusion can be reinitiated at a slower rate. Solutions carrying oxygen
Although corticosteroids (dexamethasonesodium phos- The inability to readily obtain blood products or a cross
phateat2 mg/kg i.v. or hydrocortisone at 10mg/kg i.v.) match can have life-threatening consequences. Safe and
and diphenhydramine (Benadryl, 0.5 mg/kg i.m.) are effective blood s ubstitutes are becorrung available
often used to prevent or !essen the signs of an acute commercially, after over 50 years of research and devel-
haemolytic transfusion reaction, there is currently no opment. Three categories of acellular, oxygen-carrying
objective evidence to support th is practice. Donor and plasma volume expanders exist. First are the free

Category Who le Liposome-encapsulated Stroma-free Fluorocarbon


blood haemoglobin polymerized
haemoglobin
Haemoglobin (g/dl) 14- 16 16 13 -
Osmolarity (mOsm/1) 280- 310 290 280 -
Oncotic pressure (mmHg) 25 0 25-30 20-25
Half-life (hours) Varies 15 (rats) 30-40 (rruce) 13 (humans)
P50 (mmHg) 26 18 34 -
Methaemogolobin (%) <2 13 <3 -
Fig ure 11.12: Comparison of whole blood to three different categories of red cell-free oxygen-carrying solutions.
Fluid Therapy and Blood Transfusion 137

haemoglobin-based solutions. There are at least four Gigcr U and Bücheler J ( 1991) Transfusion of type-A and type-B blood
to cats. J ournal of the American Vererinary Medical Association
different ways to solubilize haemoglobin: by intra- 198, 4 1 1-4 18
molecular cross linking, by producing polymers, by Giger U, Gelens CJ, Callan MB and Oakley DA (1995) An acute
hemolytic transfusion reaction caused by dog erythrocyte antigen
conjugating haemoglobin or by producing haemoglobin 1.1 incompatibility in a previously sensitized dog. Journal of the
rnicrospheres. To date, the haemoglobin for these solu- American Veterinary Medical Association 206(9), 1358- 1362
Gigcr U, Kilrain CG, Filippich U and Bell K ( 1989) Frequencics of
tions has been ofbovineor human origin. Alternatively, feline blood groups in the United States. Journal ofthe American
human or ovine haemoglobin has been synthesized by Veterinary Medical Association 195, 1230-1232
bacteria. The second category are liposome-encapsu- Gigcr U and Oakley D (1998) Current feline transfusion therapy: unique
issues in cats. ln: Proceedings of the Vl lnremational Ve1erinary
Iated haemoglobin solutions, with the haemoglobin Emergency and Cri1ical Care Symposium, pp. 207-2 10
being surrounded by a synthetic membrane. The third G riot-Wenk ME, Callan MB, Casai ML, Chisholm-Chait A, Spila lni k
SL, Patterson DF and Gigcr U ( 1996) Blood type AB in the fe line
category are the perfluorocarbons; organic solutions AB blood group system. American Jou mal ofVeterinary Research
with high oxygen solubility (Figure 11.12). 57, 1438- 1442
Hurst TS, T urrentine MA and Johnson GS (1987) Evaluation of
Severa) haemoglobin solutions have reached phase microwave-thawed canine plasma for transfusion. Jou mal of the
1 trials and one, Oxyglobin Solution (Biopure, Boston, American Veterinary Medical Association 190(7), 863-865
Massachusetts), was introduced in 1998 to the veteri- Joncs JA ( 1995) Red blood cell s ubstitutes: current s tatus. British
Journal ofAnaesthesia 74, 697-703
nary market in the United States. The solution is a Kirk RW and Bistner S I, eds (1985) Blood transfusions. In: Th e
polyionic colloidal fluid (130 mmol/1sodium, 4 mmolfl Ha ndbook ofVeterinary Procedures and Emerge ney Treatmem, 4'"
edn, pp. 624-625. WB Saunders, Philadelphia
potassium and llO mmol/1chloride) with a pH of7.8. It Krausz MM, David M and Amstislavsky T (1994) Hypertonie saline
has been adm inistered under a number of experimental trcatment ofhcmorrhagic shock in awake rats. S/wck2(4), 267-270
Lanier WL, Stan gland KJ, Sche ithauer BW, MildeJH and Michenfc lder
and a few clinicat conditions to over a dozen different JD (1987) T he effects of dextrose infusion and head position on
species. The recommendeddosage is 15-30ml/kg i.v.at neurologie outcome after complete cerebral ischemia in primates:
a rate not to exceed 10 mlfkgjh. If administered more examination of a mode!. Anesthesia/ogy 66, 39-48
Lee R, Atsumi N, Jacobs EE Jr, Austen WG and Vlahakes GJ (1989)
rapidly, circulatory overload may occur because of its Ultrapure, stroma-frec, polymerized bovine hemoglobin solution:
oncotic pressure (see Figure 11.12) and the increase in evaluation of renal toxicity.Journal ofSurgical Research 47,401-4 11
Lundy EF, Kuhn JE, Kwon JM, Zelcnock GB and D 'Aiccy LG ( 1987)
vascular resistance that it may cause. To date, the In fusion offive percent dextrose increases mortality and morbidity
primary concern is the potential for renal toxicity, as followingsix minutes ofcardiac arrest in resuscitated dogs.Journal
ofCritical Care 2, 4- 14
serum creatinine concentrations transiently increased in Malcolm DS, Friedland M, Moore T, Beauregard J, Hufnagcl H and
rats when they were ad rn inistered a hi gh dose (Lee et al. , Wiesmann WP ( 1993) Hypcrtonicsaline rcsuscitation detrimentally
1989). Transient haemoglobinuria has also been ob- affects renal function and survival in dehydrated rats. Circularory
Shock 40, 69-74
served in healthy Beagles. Matthew CB ( 1994) Treatmcnt ofhyperthennia and dehydration with
Perfluorocarbons may be · an ideal fluid to deliver hypertonie saline in dextran. Shock 2(3), 2 16-22 1
Mathcws KA ( 1996) Blood{Piasma transfusion. ln: Vererùwry Emergency
oxygen in situations of poor microcirculation. Twenty and Critical Care Manual. pp. 10-1 1. Life Leam, Guelph
percent F luosoi-DA (Green Cross, Osaka, Japan) has Mazzoni MC, Borgstrom P, Arfo rs KE and lntaglietta M ( 1990) The
efficacy of iso- and hyperosmot ic tluids as volume expanders in
been infused into coronary vessels during cardiac proce- fi xed-volume and uncontrollcd hemorrhage. Aunais of Emergency
dures to prevent myocardial ischaemia. Another Medicine 19(4), 350-358
perfluorocarbon, polyfluoro-octobromide (Perflubon) Miller RD (1990) Transfusion therapy. ln: Anesrhesia, 3"' edn, ed. RD
Miller, p. 1483. Churchill Livingstone, New York
may also become available soon. Additional experience Moon PFand KramerGC ( 1995) Hypertonicsaline-dextran rcsuscitation
with ali ofthese solutions is necessary to determine their from hemorrhagicshock induces transiçnt mixed acidosis. Critical
Care Medicine 23(2), 323-33 1
exact indications, contraindications and adverse effects. Moon PF, Gabor L, GlecdRDand Erb HN (1997) Acid-base, metabolic,
and hemodynamic effects of sodi um bicarbonate or tromethamine
administration in anesthct izcd dogs with experimentally induced
metabolic acidosis. American Journal of Velerinary Research
REFERENCESANDFURTHER 58(7), 77 1-776
READING Moon PF, Hollyfi eld-Gilbert MA, Mycrs TL, Uchida T a nd Kra mer GC
( 1996) Fluidcompartments in hemorrhaged rats a ft er hypcrosmotic
Auer Land Bell K ( 1981) The AB blood group system of cats. Animal crystalloid and hyperoncotic colloid resuscitation. American Journal
Blood Groups and Biochemical Genetics 12, 287-297 of Physiology 207, F l -F8
BI and RD, et al. ( 1985) Hcmodynamic and oxygen transport patterns in Nguyen TT, Zwischenberger JB, Watson WC, Traber DL, Prough DS,
surviving and nonsurviving postoperative patients. Crirical Care Hemdon DN and Kmmer GC ( 1995) Hypertonie acetate dextran
Medicin e 13, 85-90 achievcs high-flow-low-pressure rcsuscitation ofhemorrhagic shock.
Concannon KT, Haskins SC and Feldman BF ( 1992) Hemostatic JoumalofTrauma: lnjury, Infection and Critical Care38(4),602-608
defects associated with two infusion rates of dcxtran 70 in dogs. Niebauer GW ( 199 1) Autotransfusion for intraoperative blood saJvage:
American J ournal of Vererinary Research 53(8), 1369- 1375 a new technique. Compendium: Small Anima/ 13, 1105- 1116
Con roy JM, el al. ( 1996) The effects of desmoprcssin and 6% Norsworthy GD ( 1977) Blood transfusion in thecat. Feline Practice 7, 29
hydroxyethyl s tarch on Factor VIII-C. Ane:uhesia and Analgesia Rentko VT (1992) Red blood ccli substitutes. Problems in Velerinary
83, 804-807 Medicine 4(4), 647-651
Cornelius LM, Finco DR and C ul ver EH (1978) Physio logie effects of Ring J, el al. ( 1977) Frequency of anaphylactoid reactions following
rapid infusion of Ringcr's lactate solution into dogs. American infusion ofcolloid volumeexpanders. LangenbecksArch Chirurgie
Journal of Ve1erinary Research 39, 1185-1 190 Supplement, 3 1-35
Da vies MJ (1990) The role of colloids in blood conservation. /memal Strauss RG, Stansfield C, HenrikScn RA and Villhauer PJ ( 1988)
Anesthesia/ogy Clinics 28(4), 205-209 Pentastarch may cause fewereffectson coagulation th an hetastarch.
Dietz NM ( 1996) Blood substitutes: tluids, drugs or miracle solutions? Transfusion 28,257- 260
Aneslhesia and Analgesia 82, 390- 405 Turrentine MA, Kraus KH and Johnson GS (1988) Plasma from donor
Giesecke AH and Egbert LD ( 1985) Perioperativc fluid therapy- dogs, pretreated with DDA VP, transfused into a German Shorthair
crystalloids. ln: Anesthesia, cd. R Miller, pp. 13 13- 1328. Churchill Pointer with type il von Willcbrartd's disease. Veterinary Clinics of
Livingstone, New York North America 18, 275
PARTTHREE

Anaesthetic Management
CHAPTER TWELVE - -- - - -- -- - - - -- - - - -

Ophthalmic Surgery
Jacqueline C. Brearley

INTRODUCTION Influence of ophthalmic drugs on


anaesthesia
Anaesthesia for ophthalnùc surgery provides severa! Most drugs used in the treatment of ophthalmic
challenges. These include regulation of intraocular conditions are app lied topically to the conjunctival sac
pressure, prevention of the oculocardiac reflex, re- and may be given either intermittently or by continu-
stricted anaesthetist access to the patient' s head and the ous infusion. Subconjunctival injection of sorne drugs
need to avoid trauma to the surgical site on recovery allows a slow release into the tear film . Topically
from anaesthesia. Many patients presenting for cata- administered drugs inelude steroids, non-steroidal an ti-
ract surgery are a iso suffering from diabetes mellitus . inflammatory drugs (NSAIDs), antibiotics, carbollic
anhydrase inhibitors, ~-adrenoceptor antagonists,
miotics and mydriatics. In general, these have a limited
GENERAL CONSIDERATIONS systemic effect, but in susceptible individuals orthose
with severe conjunctivitis and/or uveitis, the possibil-
Vascular access ity of systemic effects should be considered.
Hindlimb venous catheterization is preferable, as it Drugs admillistered systemically include steroids,
allows maximal access without disruption to the sur- antibiotics, analgesies and diuretics (diuretics acutely
geon or surgical site. The lateral saphenous or femoral decrease intraocular pressure in cases of glaucoma).
veins may be used. AT-port extension attached to the Diuretics act either by providing a solute Joad, e.g.
catheter improves access while minimizing the risk of mannitol (0.5 g/kg i.v.), or by carbollic anhydrase
dislodging the catheter. inhibition, e.g. acetazolamide (2- 10 mg orally). Man-
nitol is the most frequently used drug for reducing
Endotracheal intubation intraocular pressure before surgery. Hydration status
The endotracheal tube (ETT) should be secured and serum electrolyte concentrations should be as-
to the bottom jaw or around the back of the head sessed before their administration.
to avoid distortion of the area around the eye,
which may occur if the tube is tied to the maxilla. Recovery
Care should be taken to avoid kinking or other Because surgery is generally fairly delicate, using fme
occlusion of the tube during positioning, draping suture material, the mùmal 's recovery from anaesthesia
and surgery. Occlusion can be difficult to detect, needs to be as smooth as possible to avoid damage to the
particularly if it is partial. Careful monitoring of surgical site. Good analgesia during and after surgery
the respiratory character, oxygenation and, if avai- will aid this. This is generally provided by systemic
lable, end-tidal carbon dioxide tension, should aid analgesies although local anaesthetic blockade may be
in thjs. A guarded ETT that contains a supporting a useful adjunct (see later). Sedation in the recovery
coil embedded in the wall should be used to prevent period may be required. Although Elizabethan collars
tube kinking if the operative procedure requires flexion may prevent self-trauma, they often cause the allimal to
of the neck. pallie initialiy, and cause distress. This may in tu rn cause
the allimal to damage itself. Paw bandages in conjunc-
Anaesthetic breathing system tion with good analgesia are usually more successful.
Any system which minimizes the amou nt oftubing and
valves near the head of the allimal is suitable. Th us the PHYSIOLOGY RELATED TO
most commonly used systems for ophthalmic anaes- OPHTHALMIC ANAESTHESIA
thesia are co-axial arrangements (Bain, Lackor Circ le)
for animais weighing over 10 kg. In allimals weighing Control of intraocular pressure
under 10 kg an Ayre' s T-piece with a Jackson-Rees The pressure withln the eye is determined by the
modification may be used. extemal pressure of the periocular structures (e.g.
142 Manual of Small Animal Anaesthesia and Analgesia

Sciera ~=----- Retina


Choroid
Ciliary cleft
Ciliary processes
Li rn bus

FLOW OF.
AQUEOUS
HUMOR
Lens
Cornea
Anterior
chamber

Posterior
chamber

Fig ure 12.1: Flow ofaqueous humor through the eye.

extrinsic muscles) on the globe and its internai struc- globe and at best can make surgery very difficult. It
tures. The most variable of the internai structures are may result in a rupture of the globe, converting
the volume of the aqueous humor (which is depend- a relatively simple conj unctival flap procedure for
ent on the rates of production and removal) and the a deep ulcer into a more complex procedure to
choroidal vascular volume, both of which can be salvage an open globe. Too low a pressure may
influenced by anaesthesia. result in distortion of the globe during intraocular
The normal intraocular pressure in dogs is 10-25 surgery, again hindering surgery and making place-
mmHg above atmospheric pressure. The aqueous ment of sutures difficult.
hum oris formed by two mechanisrns. The most impor-
tant is by ultrafiltration of plasma from the fenestrated
capillaries in the ciliary body processes. This is an Increase intraocular pressure
active enzymatic process involving carbonic anhy-
Increased venous pressure (increases blood
drase. The second mechanism involves secretion of
solutes from the ciliary epithelium, with accompany- volume in eye) caused by coughing, vomiting,
ing water. The fluid is secreted into the posterior retching and 'bucking' on endotracheal tube
chamber and then flows into the anterior chamber Increased arterial pressure
through the pupil. From the anterior chamber the Hypercapnia
aqueous humor drains into the uveal veins through the Hypoxia
trabecular meshwork of Fontana at the angle between Increased pressure on globe (blepharospasm,
the iris and the cornea (Figure 12.1), finally reaching orbital tumours)
the jugular veins. Drugs (atropine, suxamethonium)
It is within the power of the anaesthetist to control
intraocular pressure to sorne extent by controlling Decrease intraocular pressure
arterial blood pressure, central venous pressure and Decreased venous pressure
end-tidal carbon dioxide tension. These factors gener- Decreased arterial pressure
ally influence the rate of aqueous production (rather Hypocapnia
than rate of removal) and the choroidal vascular vol-
High arterial oxygen tension
ume. A fuller list of factors that influence intraocular
Majority of anaesthetic agents
pressure is shown in Figure 12.2.
Osmotic diuretics
The airn of the anaesthetist should be to maintain
intraocular pressure within normal limits. T oo high Carbonic anhydrase inhibitors
a pressure at worst may risk the evisceration of the Figure 12.2: Factors influencing intraocular pressure.

[ ...
Ophthalmic Surgery 143

The oculocardiac reflex atracurium (0.2- 0 .5 mg/kg). This produces a central


It has been known for many years that traction on the immobile eye, which will not vary its position with
extrinsic muscles of the eye can result in slowing of the depth of anaesthesia. The disadvantage of this method
heart and the development of bradydysrhythmias, e.g. is that intermittent positive-pressure ventilation is man-
asystole, atrioventricular block and puis us bigeminus. datory as the respiratory muscles will be paralysed, in
This reflex is mediated on the afferent side by branches addition to the extrinsic eye muscles. The duration of
of the ciliary nerves (which in tu rn are branches of the action of vecuronium at the above dose is approxi-
trigeminal nerve) and on the efferent side by the mately 20 minutes and that of atracurium 40 minutes.
carpiac branches of the va gus nerve (Figure 12.3). This An acetylcholinesterase blocking agent (e.g. neostig-
reflex is relatively rare in adult dogs and cats, to the mine or edrophonium) should be administered at the
extent that prophylactic vagal blockade by an anti- end of surgery to increase acetylcholine concentra-
cholinergic drug is unwarranted. However, in animais tions at the neuromuscular junction. The muscarinic
with high va gal tone (e.g. very young animais), consid- effects of these drugs (bradycardia, salivation, etc.)
eration should be given to preventing or blocking this should be blocked by the concurrent use of an anti-
reflex. This can be achieved by gentle handling of the cholinergic, e.g. atropine (0.04 mg/kg) or glycopyrrolate
globe, the use of local anaesthetic blockade (with its (0.02 mg/kg) (see Chapter 10).
inherent problems) or pretreatment with an anticholin- A central eye position may also be achieved using
ergic drug approximately 30 minutes before surgery. local anaesthetic techniques. Regional anaesthesia of
Atropine (0.04 mg/kg) or glycopyrrolate (0.02 mg/kg) the eye and orbit may be produced either by blocking
by intramuscular or subcutaneous injection is said to the ophthalmic branch of the trigeminal nerve, or by
be effective. However, routine premedication with retrobulbar deposition of local anaesthetic.
these drugs is not advocated for ophthalmic surgery. Ophthalmic nerve block requires deposition of
approximately 1-2 ml of local anaesthetic solution
Central eye position (either2 % lignocaine(lidocaine)or0.5 % bupivacaine)
The production of a central eye to ease surgi cal access close to the orbital fissure. Because of the close prox-
for ocular and intraocular surgery is generally in the imity of this nerve to the abducens, oculomotor and
hands of the anaesthetist. In the dog un der a light plane trochlear nerves, akinesis of the globe also results.
of anaesthesia, the eye is central, but surgical stimula- A 2.5 cm, 22 gauge needle is introduced ventral to
tion at this point will cause retraction of the eye into the the zygorriatic process, approximately 0.5 cm cranial
socket. At a plane of surgical anaesthesia, the eye to the rostral border of the vertical ramus of the
rotates down causing the corÎlea to be obscured under mandible. The needle is advanced in a medial, dorsal
the nictitating membrane and the lower eyelid. Deeper and caudal direction so that its tipis close to the orbital
planes of anaesthesia, wh ile giving a central eye, are fissure. Close inspection of a skull is recommended
associated with excessive physiological depression, before this technique is attempted.
increasing the risks of respiratory arrest (without Retrobulbar anaesthesia is associated with a higher
ventilatory support) and cardiac arrest. morbidity than ophthalmic block. Complications
Traditionally, a central pupil has been produced include subarachnoid injection of local anaesthetic,
during a plane of surgi cal anaesthesia by traction on the -intravascular injection and punc ture of the globe.
globe either by stay sutures or by manipulation with a Needle insertion can be either at the lateral canthus
pair of forceps on the conjuncti va. These methods cause (directing the needle towards the opposite tem-
trauma to the eye and can interfere with surgical access. poromandibular joint), or at the most dorsal point
The most reliable method is to use a non-depolar- on the curvature of the orbit and following the
izing muscle relaxant e.g. vecuronium (0. 1 mg/kg) or orbit around ventrally.

ŒD--- Eye
Trigeminal nerve

~_)'\....._/~/' Central nervous system


~

Heart Vagus nerve


Figure 12.3: The oculocardiac reflex.
144 Manual of Small Animal Anaesthesia and Analgesia

FACTORS INFLUENCING THE Will acepromazine alone be sufficient in low


CHOICE OF ANAESTHETIC REGIMEN doses? If the self-mutilation is due to discomfort,
analgesia will also be required. If opioids are used,
Choice of anaesthetic regi men depends on the surgi cal a smaller dose of acepromazine should be needed
procedure proposed, the temperament of the animal • Is the animal very nervous?
and the envisaged length of hospital stay. Obvious ly
the surgical procedure takes precedence, but other These are examples of the types of questions that
factors are also important. should be considered and that play a role in determi•i-
ing the drugs used in a particular case.
Day case or inpatient
If ali other factors are equal, the length of hospital stay
envisaged will generally depend on the subsequent EXAMPLESOFPROTOCOLSFOR
treatment for the ophthalmological condition or other
SPECIFIC PROCEDURES
concems with the eye. For example, intraocular surgical Surgical conditions can be divided in terms of ana-
patients are often hospitatized for more than 24 hours tomical sites. These are:
postoperati vely in case extensive uveitis develops or
the aqueous humor starts to leak. Patients may be Periocular surgery
hospitalized to ensure regular postoperative medication • Ocular surgery
e.g. two-hourly eye drops, which may be impossible for • Intraocular surgery.
the owner to administer, orto keep the animal quiet and
away from its home surroundings, which may excite it. Anaesthesia for periocular surgery
In such cases a longer-acting agent or combination of
agents may be chosen, as a rapid recovery is neither Types of procedure
desirable nor necessary. Therefore, thiopentone may be
chosen over propofol, or halothane over isotlurane. • Eyelid surgery, e.g. entropion, ectopie cilia,
Longer postoperative stay will also allow the adminis- distichiasis
tration of opioid analgesies for postoperative analgesia, Parotid duct transposition
which would not be possible if the animal was treated as 'Face lift' procedures for severe entropion
a day case. Nasolacrimal ductjpuncta surgery.

Surgical considerations
Temperament of the animal
The treatment of cats differs slightly from dogs . Be- Chronic painful conditions
cause of their temperament, and often because of the Surgical site often subject to swelling
degree of socialization that the animais have previ- · Intlammatory process can disrupt surgical site
ously experienced, cats may not adapt weil to the Surgery often relieves discomfort to sorne extent
hospital environment. This frequently makes the an- immediately after anaesthesia
aesthetic and analgesie treatment of cats for ophthal- Often a day case.
mological conditions a challenge.
Questions which should be asked regarding the Premedication
temperament include: Systemic analgesies are very useful preoperatively
as pain, lacrimation and blepharospasm are often
• Is the animal safe to be nursed, or is it too presenting signs of chronic eyelash irritation of the
aggressive in the hos pital environment? If the comea. Keratoconjuctivitis sicca (dry eye) can cause
latter is the case, then regardless of the medical/ thedogdiscomfort, but this is most effectively relieved
surgical condition, the animal may be treated on by the application of artificial tears rather than a
a day-case basis with a premedication that systemic analgesie.
a llows safe handling before anaesthesia but The partial opioid agonists are genera li y adequate,
sufficient return of consciousness e.g. buprenorphine at 0.01 mgjkg or butorphanol at 0.2
postoperatively togo home soon after surgery. mgjkg. Buprenorphine, with its relatively long dura-
Thus medetomidine in combination with an tion of action, may have a particular role in these
opioid could be used as the premedicant, with procedures as it is a potent analgesie that will provide
the cx.2 -agonist being reversed at the end of good immediate postoperative analgesia and will al-
surgery to give a more rapid recovery but low a smooth transition to an NSAID for more pro-
leaving the opioid to act as an analgesie in the longed postoperativeanalgesia if required. The problem
immediate postoperative period with these cases is that the animais have often been in
Is the animallikely to inflict postoperative self- discomfort for sorne time and so may be sensitized to
trauma and therefore require postoperative irritants around the eye, making the control of pain
sedation to safeguard the surgical site? more difficult in sorne cases.
Ophthalmic Surgery 145

The NSAIDs have a particular role to play in Catheterization of the latera l saphenous vein
periocular surgery for the control of postoperative should be practised in positions otherthan lateral recum-
swelling and thereby limiting distortion of the surgi- bency, because many animais may resent this position
cal site. but be perfectly happy when standing, or 1ying in sternal
recumbency. The use of a T -port extension attached to
Induction of anaesthesia the catheter allows injection of the induction agent with
Most of the common induction agents, e.g. propofol minimal restraint or support of the animal.
and thiopentone, are suitable. The choice will often
depend on whether the animal is a day patient or not. Induction of anaesthesia
Propofol con fers the advantages of a smooth complete Choice of induction agent is more dependent on consid-
recovery, with no ' hangover' effect. This makes it erations other than the surgical procedure proposed (see
ideal for day-case surgery. above). However, an injectable agent is recommended
rather than an inhalational technique. A smooth induc-
Maintenance of anaesthesia tion is very important in these cases as any struggling or
While many of the procedures under this heading are excitement will increase intraocular pressure.
relatively minor, they are not necessarily short, e.g.
Endotracheal intubation should only be attempted
complex entropion/ectropion corrections. For short when the animal is sufficiently deep to allow this
procedures, intravenous maintenance with propofol procedure without 'bucking' on the ETT. Such buck-
may suffice, but inhalational anaesthesia is prefer- ing will increase intraocular pressure and again may
able for more prolonged (>20 minutes) surgery. cause globe disruption. The use of suxamethonium
Isoflurane may have a slight advantage over haloth- (succinylcholine) to facilitate endotracheal intubation
ane as a maintenance agent, due to the more rapid of cats is contraindicated in cases with deep corneal
recovery. If intravenous maintenance is chosen, oxy- ulcers because it increases intraocular pressure.
gen supplementation should be provided either by
nasal tube or via an orotracheal tube, as respiratory Maintenance of anaesthesia
depression is common with propofol. Whichever Methods of maintenance of anaesthesia are again
maintenance technique is chosen, routine monitoring dependent on factors other than the surgery, but a central
of anaesthesia should be undertaken, however short eye may be required (see section on central eye position).
the procedure.

Anaesthesia for ocular surgery Anaesthesia for intraocular surgery

Types of procedure Types of procedure

Foreign body removal Intraocular foreign body removal


Keratectomy Extracapsular cataract extraction
Peribulbar sampling Phacoemulsification of cataracts
Enucleation Luxated lens extraction
Conjunctival flap Intraocular tissue sampling.
Laser treatment for glaucoma.
Surgical requirements
Surgical requirements
Central eye
Central eye if corneal surgery is contemplated Controlled intraocular pressure
Relaxed eye without retraction into orbit Neutra! pupil which can be controlled topically
Minimization of haemorrhage - particularly with Control of perioperative uveitis .
enucleations
Preservation of an intact eye, particularly with Premedication and preparation
deep corneal ulcers or foreign bodies. Many patients with cataracts also have diabetes mellitus.
Assessment of blood glucose levels should be part of
Premedication and preparation the preoperative examination of all animais with cata-
Careful preoperative handling is required to avoid racts. (See Chapter 19 for details on anaesthetizing
rupture of an eye with a deep corneal ulcer, and to diabetic patients.)
a void movement of corneal foreign bodies. This will Topical treatment with ~nti-inflammatory agents
be aided by adequate sedation and analgesia . (e.g. flurbiprofen or prednisolone) for severa! hours
Premedicants which may induce emesis (e.g. mor- before surgery is thought to decrease postoperative
phine, medetomidine, xylazine) should not be given uveitis. If a dilated pupil is required, this can be
because vomiting will increase intraocular pressure achieved with topical atropine (or tropicamide) before
and may result in disruption of the eye. surgery. The animal should be premedicated with a
146 Manual of Small Animal Anaesthesia and Analgesia

systemic opioid and sedative to ensure a calm animal (which induce mydriasis) should be avoided, as topical
for induction of anaesthesia. A systemic NSAID is a Iso control of the pupil size provides the surgeon with
thought to help in the control of postoperati ve uveitis. much more flexibility.
Unless blood pressure is measured during surgery, the
administration of the majority of this class of drugs is Induction of anaesthesia
best left to the recovery period because intraoperative Choice of agent depends on the anaesthetist and factors
hypotension in conjunction with an NSAID may lead other than the procedure, as discussed above. ·
to subsequent renal damage. Sorne ophthalmologists
use a steroid, e.g. dexamethasone, to aid in the control Maintenance of anaesthesia
of postoperative uveitis. A central eye is necessary for most of the procedures in
Premedication with either high-dose pure opioid this group, and details may be found in the section on
agonists (which induce miosis) or anticholinergics central eye position.
CHAPTER THIRTEEN - - - - - - - - - - - - - - - - -

Dental and Maxillofacial Surgery


Tanya Duke

INTRODUCTION Possible problems duri ng manipulations of the head


include kinking of the ETT, extubation and circuit
The type of patient presented for dental or maxillo- disconnections. These problems are common during
facial surgery can vary, but many will be geriatrie or diagnostic imaging as the patient has to be positioned fo r
have brachycephalic anatomy. In s uch patients, an- radiography in a darkened room. In spontaneously breath-
aesthesia can pose a great risk. The type of s urgical ing patients, inadvertentdisconnection allowsair breath-
procedure may a Iso infl uence the course of anaesthe- ing, reduced inspired anaesthetic concentrations and
s ia by introducing risks to ai rway security or the decreased depth of anaesthesia. Surgical drapes can
possibility of haemorrhage. conceal circuit disconnections un less sudden emptying
of the rebreathing bag is observed. Apnoea alarms and
capnograms are useful for detecting accidentai discon-
PRINCIPLES AND POTENTIAL nection. Inspiration against an obstructed airway caused
PROBLEMS by a kinked ETT may lead to pulmonary oedema.
Guarded endotracheal tubes (see Chapter 4) may be
Airway security used in patients at high risk of endotrachea 1tube kinking.
D uring s urgery for denta l and maxillofacial condi-
tions, the airway should be adequately secured by Long anaesthetic periods
endotracheal intu bation , as debris, blood and Close attention to !ife support is needed during lengthy
irrigation fluids from the oral cavity can enter surgical procedures that require prolonged anaesthe-
unprotected a irways and cause aspiration pneumo- sia. Oxygen should be de livered at an inspired concen-
nia. This condition, which can be fata l, is easier to tration of at !east 33% to compensate for the
prevent than cure. deterioration in pulmonary fu nction that accompanies
anaesthesia (hypoventilation, reduced fu nctional re-
Endotracheal tubes s idual capacity (FRC), atelectasis and ventilation/
Endotracheal tubes (ETTs) should be checked for perfusion mismatch), even in healthy young patients.
defective cuffs and obstructed lumens before use. The Reduced cardiac output and arterial blood pres-
tubing should be eut to fit the patient from mid neck to s ure produced by a naesthesia should be offset by
the leve! of the incisor teeth. A properly positioned intravenous fl uid therapy. Intravenous Hartmann's
ETT reduces apparatus dead space and the ris k of (lactated Ringer's) solution s hould be given at a rate
endobronchial intubation. Excessive!y long ETTs that of 10 inl/kg/h. Before induci ng anaesthesia, a cath-
protrude from the oral cavity are prone to kin ki ng and eter should be aseptically placed into an appropriate
are difficult to sec ure to the jaw with ga uze bandage. superficia l vein. Catheters ens ure that irritant inject-
Knots placed around the ETT can become sodden by ab le agents are not given peri vascularly, and they a iso
irrigation fl uids and saliva, and may loosen and in- allow immediate venous access in an emergency.
crease the ris k of accidentai extubation. Knots s hould Catheters s hould not be removed until the patient is
be tied around the ETT connector for greater security full y conscious after anaesthesia.
and not around the ETT itself. Hypothermia can result from lengthy anaesthesia
and the use of cool irrigation fl uids. It can cause
Pharyngeal packing anticho linergic resistant bradycardia, reduced cardiac
Pharyngeal pac king can be used for greater airway output and haemoconcentration, and cardiac fibrilla-
security, but it is imperative that it is removed before tion can occur at a body temperature of about 28°C.
extubation. A length of damp gauze bandage is s u- Requi rements for anaesthetic agents are reduced dur-
perior to individual surgical swabs sinee bandage can ing hypothermia, and care should be taken to avoid a
be packed tightly around the ETT, and is less likely to re lative overdose of anaesthetic agent. Externat heat
be forgotten if the free end is left visible. can be supplied with heating blankets and warmed
148 Manual of Small Animal Anaesthesia and Analgesia

intravenous and irrigation fluids. Thermal injuries due of poor analgesia. Opioids should be provided at the
to ' hot spots' are rarely produced by circulating warm time of premedication, and local nerve blocks should
water blankets, but occur more often with electrical be considered before s urgery (see below). Further
heating mats. Patients can be insulated with towels, increments of injectable opioids can be provided
bubble packing or aluminium foil. H yperthermia can intraoperatively, or nitro us oxide can be given. Analge-
occasionally occur in large heavy coated dogs con- sies should be continued into the recovery period.
nected to rebreathing circuits for long periods. In s uch
cases, acti ve cooling should be initiated before damage
occurs to vital organs. PATIENTS REQUIRING DENTAL
PROCEDURES
Haemorrhage
B lood Joss and hypovolaemia may occur du ring sorne Geriatrie patients
dental and maxillofacial procedures. B lood lossshould Dental procedures range from s imple extractions of
beestimated either by weighing blood soaked swabs or deciduous teeth in young healthy patients to lengthy
by measuring the amount of blood collected in a complicated procedures in o ldersystemically compro-
s uction jar. As a rough guide, a full y soaked 3 x 3 inch mised patients. Most patients requiring anaesthesia for
swab contains about 7 ml of blood, and a 4 x 4 inch dental procedures are considered to be geriatrie (i.e .
swab contains about 10 ml of blood. The normal 75-80% of the animal's anticipated !ife span is com-
patient can tolera te blood Joss of up to 20 % of circulat- pleted). Even clinically healthy geriatrie patients have
ing volume through compensatory mechanisms, but physiological changes that can influence the course of
these mechanisms are not as efficient when the patient anaesthesia. Elderly patients are often distressed and
is anaes thetized. Rates of intravenous isotonie confused by a change in routine and require constant
crystalloid fluid infusion should be increased to 30-40 reassurance. Age-related changes in the cardiopulmo-
ml/kg/h to compensate for hypotension. As the blood nary system include:
Joss approaches 20 % of circulating volume, fluid re-
placement therapy with blood should begin. Colloids Decreased ability to compensate for blood
s uch as gelatins, dextrans or starches can be used at a pressure and circulating vo lume changes
dose of up to 20 ml/kg, but while they s upport tissue 30% decrease in cardiac output
perfus ion they are not a replacement for red blood Decreased Jung compliance
cells. If haemorrhage is anticipated during the proce- High small airway closing volume
dure, patients s hould be cross matched beforehand Decreased partial pressure of oxygen in arterial
with a healthy donor. Donor blood should be given at blood (Pa02 ).
the same rate that the patient's blood is !ost.
An alternative to cross matching with a donor is A noticeable decrease in circulation time is seen
autologous transfusion. A week before surgery, 10% of during induction, and further increments of injectable
the patient's blood volume is removed and replaced with anaesthetic agents s hould not be given too soon. See
intravenous fluids . The blood is stored at 4°C in acid- Chapter 23 for further information on anaesthesia for
citrate-dextrose or citrate-phosphate-dextrose trans- the geriatrie patient.
fusion packs until required. In any case, before poten-
tially haemorrhagic procedures, the patient must have Brachycephalic patients
a full haematological examination and clotting profile Many brachycephalic patients require dental or maxil-
performed. See Chapter 11 for further information. lofacial procedures, and these patients pose an anaes-
thetic challenge. Upper airway obstruction from stenotic
Haemostasis nares, an elongated soft palate, laryngeal saccule ever-
Vasoconstrictors such as topically applied adrenaline sion, laryngeal collapse, laryngeal oedema and hy po-
should not be used for haemostasis if the patient is plastic trachea should be anticipated. The degree of
anaesthetized with halothane. A few drops can be used obstruction may be assessed from the clinical history
with caution in a 1:20,000 dilution if the patient is anaes- and a physical examinati on before surgery.
thetized with isoflurane, and monitored by electro- Problems of the upper airway may benefit from
cardiography. Phenylephrine at the sa me dilution is Jess surgical correction at the time of planned dental proce-
arrhythmogenic, but even a few drops of this drug can be dures. Severe upper airway obstruction eventually
absorbed sufficiently to increase systemic vascular re- results in cor pulmonale, and evidence for this should
sistance through adrenergic receptor stimulation. be checked. Induction of anaesthesia causes relaxation
of pharyngeal musculature, and the degree of upper
Analgesia airway obstruction is increased until endotracheal in-
Sorne dental and maxillofacial procedures produce tubation is performed. Potent sedative agents such as
strong surgical stimulation, resulting in a variable plane xylazine sho uld be avoided during premedication as
of anaesthesia. A widely varying plane is often the res ult these exacerbate upper airway obstruction.
Dental and Maxillofacial Surgery 149

Mild sedation with low doses of acepromazine considered to be routine, and clients may believe that
and buprenorphine or pethidine (meperidine) is ade- anaesthetizing their pet will be straightforward . In
quate in dogs . Boxers are prone to vasovagal syncope elderly patients there is increasing likelihood of
with acepromazine and either should receive an systemic disease that may have gone unnoticed by
anticholinergic or phenothiazine should be avoided. the client. A thorough examination helps to eliminate
Fractious dogs should not be muzzled, but an Eliza- proble ms in the perioperative period. E lective
bethan collar can prevent handlers from being procedures can be delayed until the patient is stable,
injured. Preoxygenation by mask for 5 minutes will and urgent procedures can be undertaken with the
help prevent hypoxia during induction, but mask clinician (and client) cognisant of problems that
induction using an inhalational agent should be may occur. Further information regarding systemic
avoided where possible. A rapid reliable induction disease and anaesthesia may be found in other chap-
technique should be used with drugs such as ters on anaesthetic management.
methohexitone, thiopentone or propofol and endo-
tracheal intubation expertly performed. Premedication
Airway obstruction is possible during recovery. Many geriatrie patients are likely to be distressed
There are two methods of dealing with airway sup- by the upheaval in their routine and being with
port in the recovery period. Firstly, opioids with strangers in unfamiliar surroundings. Premedication
patent anti-tussive action, such as butorphanol, mor- provides a calming effect and makes the patient more
phine or oxymorphone, can be given to dogs to allow manageable. Important considerations for dental
toleration of the ETT for as long as possible, even anaesthesia include the provision of intraoperative
until they are stern al. A disadvantage is that complete analgesia with an opioid, the ability to reduce the
recovery may be lengthy. Second! y, induction drugs amount of major depressant anaesthetic agents and
with relatively short plasma half-lives, such as the reduction of undesirable side effects. Combi-
methohexitone, propofol or a benzodiazepin e/ nations of acepromazine and opioid are suitable in
ketamine combination, ensure a rapid recovery and most cases. Alpha2 -adrenoceptor agonists should
return of the patient's ability to maintain its own only be used in young healthy patients, and only when
airway. Isoflurane provides more rapid recoveries there is a full appreciation of the side effects. Oxygen
than halothane. and ventilatory support must be available when these
Even after ta king these precautions, once the ETI is drugs are used.
removed there is still a risk of obstruction until the Anticholine rg ics can reduce undesirable
patient is full y awake. Obstruction can be alleviated by parasympathetic effects such as salivation and brady-
pulling the patient's tangue forwards and keeping the cardia. Glycopyrrolate has a duration of action of
mouth open to encourage mouth breathing. Hypoxia can 2-3 hours and is a more patent anti-sialagogue than
be alleviated by giving oxygen. Placing the patient in atropine. For further information see Chapter 7.
sternal recumbency allows more uniform expansion of
the lungs and may promote a more rapid return to Induction
consciousness. If recovery is delayed because the The passage from consciousness to unconsciousness
patient has been given a patent 11-agonist, such as should be as smooth and excitement-free as possible.
morphine, methadone or oxymorphone for analgesia, In healthy patients methohexitone, thiopentone,
and the patient has been extubated, an alternative to propofol and alphaxolonejalphadolone are recom-
reintubation may be to reverse the 11-agonist. Ifnaloxone mended as they produce a reliable rapid induction. In
is used for this purpose to reverse sedation, analgesia is patients with cardiopulmonary compromise or severe
also reversed. To avoid this unintended scenario, hepatic or renal disease, they should be used with
butorphanol (0.2 mg/ kg slowly intravenously) or caution (see Chapter 14). Xylazine/ketamine or
buprenorphine (0.006 mg/kg i.v.) can be used for medetomidinejketamine combinations for induction
reversai. Butorphanol produces reversai 1-2 minutes of anaesthesia should not be used in geriatrie or
after injection, but buprenorphine can take 10-15 min- debilitated patients. See Chapter 8 for further details
utes. It is wise to be prepared to perfonn tracheostomy regarding injectable drugs.
on patients that present with upper airway obstruction.
Maintenance
For short procedures of less than 15 minutes, incre-
ANAESTHESIA FOR ROUTINE mentai boluses of short-acting injectable anaesthetics
DENTAL PROCEDURES such as methohexitone, thiopentone, propofol,
benzodiazepinejketamine- and alphaxolonefalpha-
Preanaesthetic preparation dolone can be used. Dental procedures, however, can
lt is important to ensure that a thorough clinical be lengthy and this increases the risks of deterioration
examination has been performed on the patient in physiological status, especially in elderly compro-
before giving an anaesthetic. Many procedures are mised patients, and anaesthesia is best maintained with
r1
150 Manual of Small Animal Anaesthesia and Analgesia

an inhalational technique. Inhaled anaesthetics are inspected for fl uids, blood clots and foreign abjects
usually administered in an oxygen-enriched mixture and any removed. Suction apparatus is useful to ensure
and this greatly improves oxygen delivery to tissues. that the pharynx is dry.
Delirious recoveri.es may be the result of pain,
excitatory anaesthetic agents or hypoxia. Patients re-
MAXILLOFACIAL TRAUMA covering from oral surgery often try to rub their faces,
AND ELECTIVE MAXILLOFACIAL and sedatives, analgesies or an Elizabethan collar may
SURGERY he lp prevent self-inf licted tra uma. For restless
patients, acepromazine can be given at a low dose (0.02
Patients requiri ng elective procedures such as hemi- mg/kg i.v.). Some patients greatl y benefi t from oxygen
mandibulectomy need to be thoroughly examined and given during recovery. Oxygen can be supplied by
any concurrent disease stabilized be fore anaesthesia is mask or by a nasal catheter placed before recovery.
induced. Any consequences of the surgical procedure Ana lgesies should be provided pre- or intra-
(e.g. haemorrhage) should be anticipated. The upper operatively, but may requ ire s upp lementation (see
airway should be examined fo r potential difficulties in Chapter 6). Opioids are the analgesies of choice for the
intubation. Patients with traumatic injuries must be perioperative period. Local anaesthesia can be pro-
stabi 1ized and other potential injuries addressed before vided by using mandibular and maxillary nerve blacks
anaesthesia. See Chapter 21 for further information with 2 % lignocaine (lidocaine) or 0.5 % bupivacaine.
regard ing patients with trauma. Most procedures can Bupivacaine provides longer analgesia than ligna-
be managed with conventional orotracheal intubation, caine. Aspiration s hould be attempted before injection
but occasionally passing the ETT through a pharyn- to ensure that the analgesie drug is not injected into a
gotomy site or a tracheotomy may be necessary. blood vesse!. Nerve blacks can be performed be fo re or
Preoxygenation should be performed in case there after surgery, but placing the local anaesthetic before-
are difficulties in intubation. Once the patient is hand can decrease the amount of other anaesthetic
stable, rapid sequence induction techniques after light drugs needed and lower the postoperative requirement
premedication can be used to establis h an airway. for analgesies .
Maintenance of anaesthesia can be provided by
inha lational techniques. Positioning for s urgery is Maxillary nerve block
important and the ETT m ust be secure ly tied to This desensitizes the maxilla, upper teeth, nose and
prevent accide ntai disconnections . Right-angled upper lip.
!
adaptors can be attached to the ETT adapter to For this nerve block, a needle (A, Figure 13.1) is
:1 ena ble breathing circuits to be diverted away from the inserted at an angle of 90 degrees media li y, ventral to
1
surgical site. B reath ing circuits s uch as Bain, Lack, the border of the zygomatic process, and approxi-
A y re 's T -piece and circle systems are useful because mately 0.5 cm caudal to the lateral canthus of the eye.
they do not have heavy valves at the patient end of the The local anaesthetic (0.25-1.0 ml) is deposited around
c ircuit, which could place drag on the ETT. the maxillary nerve as it crosses the palatine bone,
Monitoring a ids are useful, becausesurgical drapes between the maxillary foramen and fora men rotundum.
may make examination of eye position impossible.
Cats should be closely watched duri ng recovery, as Mandibular nerve block (inferior alveolar
they are prone to upper airway obstruction ifthe nasal bran ch)
passages are occluded with blood and debris. Unti l This desensitizes the lower teeth and lower lip.
cats are fully recovered from the effects of the anaes- For this nerve black, a needle (22 or 25 gauge, 1.9
thetic, they seem reluctant to mouth breathe during cm or 2.5 cm) is inserted at the lower angle of the jaw
the critical ti me from extubation. Anaesthetic agents approxi mately 1.5 cm rostral to the angular process.
providing rapid recovery are useful to decrease the The needle (B, Figure 13.1) is passed dorsally along
ti me from extubation until the catis full y aware of its the medial surface of the mandibular ramus. The man-
surround ings. Analgesies without major sedative dibu lar foramen can be palpated withi n the oral cavity
effects, s uch as buprenorphine or butorphanol, can be and the needle point guided accurately to the nerve.
used without delay ing recovery. Oxygen can be pro- Cats require 0.25 ml of local anaesthetic and dogs
vided through a preplaced nasal catheter, mask or req uire 0.5-1.0 ml.
li head tent (see Chapter 21).

SPECIAL TECHNIQUES
RECOVERY AND ANALGESIA
Placement of a nasal oxygen catheter
Good nursing, analgesies, warmth, fluids and continu- After instilling a few drops of2 % lignocaine (without
e us observation help to eliminate postoperative prob- adrenaline) on to the nasal mucosa, a lubricated 3.5-6
lems. Before extubation, the pharyngeal area s hould be Fr polyvinyl infant feeding tube is advanced into the

1
Dental and Maxillofacial Surgery 151

Figure 13.1: Positioning ofneedle during maxillary (A) and mandibular (B) nerve block in the dog.
Similar positioning is used in the cat.
Reproduced from Muir afld Hub!Je/1 ( 1995) u·iril permis.~"ion ojMosby /ne.

ventral nasal meatus to the leve! of the carnassial tee th. the oral cavity. Forceps may be thrust through the
The tube is secured to the head by buttertly tapes and mucosa and then used to grasp and pull the proximal
sutures. A drop of cyanoacrylate glue deposited be- end of the ETT lateral! y. The incision can be closed in
tween the tube and nostril helps to secure the tube a routine manner once it is not required.
where it makes a tight turn caudally (Figure 13.2).
Extension tubing connects the nasal tube to an oxygen Elective tracheotomy
flowmeter, and oxygen is insufflated at a flow rate of A patient that can otherwise breathe normally but
50-150 ml/kg/min. If oxygen insufflation is to be used cannat open the mouth, should be induced and main-
for more than a few hours, the gas should be humidified tained with incrementai boluses of a non-cumulative
by bubbling it through sterile water. anaesthetic agent such as propofol until the jaws are
opened or a tracheotomy is performed.
Pharyngotomy for diversion of the ETT
Occasionally, the ETT may be required to pass
from the trachea through a temporary pharyngotomy
to connect with the breathing circuit. This allows
the surgeon access to the oral cavity without the
hindrance of an ETT. Once the ETT is in place, a
pharyngotomy can be performed and the proximal end
of the ETT removed from its adaptor and passed
mediolaterally through the pharyngotomy site, and the
adaptor reconnected a llo wing anaesth es ia to
continue with an inhalational teclmique. Injectable
anaesthetic drugs may be required to maintain anaes-
thesia during movement of the ETT. Propofol is useful
for this as it does not accumulate with repeat bol uses,
but thiopentone can also be used for one or two
incrementai boluses.
After surgi cal preparation of the cervical a rea and
angle of the mandible, an index finger is introduced
into the oral cavity. The finger is used to locate the Figure 13.2: Cat with nasalline delivering oxygen. The
pyriform sinus rostral to the epihyoid bone (Figure nasalline is secured in place with tissue glue, and butterjly
13.3). The tissues are incised and dissected through to strips are sutured to the head.
152 Manual of Small Animal Anaesthesia and Analgesia

Figure 13.3: Placemem of endotrachealtube through pharyngoromy site.


Reproducedfrom Mu ir mu/ 1-lubbt!ll ( 1995) with permission of Mosby lr1c.

Elective tracheotomies can be performed under trostomy tube offers an alternative method of provid-
aseptic conditions while there is an orotracheal tube in ing nutrition and fluids (Crowe, 1986).
place. The ventral surface of the trachea at the leve! of
the second, third or fourth tracheal rings is exposed by Indwelling nasogastric intubation
a midline incision and the sternohyoideus muscles After desensitizing the nasal mucosa, a lubricated 5 or
retracted. Two stabilizing sutures are placed around 6 Fr polyvinyl infa nt feeding tube is passed into the
the tracheal rings at the site of tracheal incision to ventral nasal meatus. Placement into the oesophagus is
facilitate apposition later. A transverse incision be- easy in the tracheally intubated anaesthetized patient.
tween the rings is made through the annular ligament In conscious patients the head should be held with the
and mucosa up to 65% of the circumference of the nose pointing down while the tube is advanced as this
trachea. Alternative!y, a U-shaped ventral tracheal flap he lps prevent accidentai insertion into the trachea. The
is created based on the second tracheal ring and extend- tube should be advanced until the distal end is posi-
ing two rings distally. T he flap is raised as a hinge to tioned in the distal oesophagus (preferred location) or
allow placement of the ETT. This flapis used for long- in the stomach. The stylette, if used, should then be
term intubation as it prevents excessive pressure of the removed. Placement should be verified by radiogra-
tube on the surrounding tissue. Postoperatively, the phy or by auscultation of bubbles when air or sterile
incision should be left to granulate, but this does saline is instilled through the tube. The tube should
requ ire intensive ca re to allow cleaning of the trache- then be capped and sutured in place with butterflies
otomy site, and constant observation of the patient. made from sti c;ky tape. An Elizabethan collar will be
Sorne clinicians pref e r to c lose the inc is io n necessary in some patients to prevent them from re-
postoperatively, but there may be a risk of subcutane- moving the tube. Although this technique is easy to
ous emphysema, localized swelling and subsequent perform, it is limited to short periods of feeding with
risk of airway obstruction. liquidized foods.

Feeding tubes Pharyngostomy tube


In patients that cannot feed and drink normally, a A technique similar to that described for a pharyn-
nasogastric, pharyngostomy, oesophagostomy or gas- gotomy tube can be used, but long-term maintenance
Dental and Maxillofacial Surgery 153

can result in dysfunction of the larynx and aspiration. dogs, an incis io n can be made. The feedi ng tube is
The technique of placement is therefore modified slightly premeasured and marked from stomach or distal
so that the tube exits as caudodorsally as possible, close oesophagus to incision site. The distal end is grasped
to the entrance to the oesophagus. ln the modified by the forceps and pu !led through the oesophagus out
technique, the incision is made in the lateral wall of the of the mou th. With the a id of forceps the distal end is
pharynx, caudodorsal to the hyoid apparatus. then turned o n itself to pass back into the oesophagus
until the loop disappears. The distal tip is correctly
Oesophagostomy tube positioned using the mark on the tube. This method
This s ite is currently the preferred pos ition for place- he lps to straighten th e tube and li mit kinks (Crowe and
ment of a feeding tube. It avoids the complications of Devey, 1997).
peritonitis from gastrotomy tubes, and the risks of
aspiration and damage to mucosa from the previo usly
described sites. Under anaesthesia, the lateral cervical REFERENCESANDFURTHER
region is clipped and prepared for surgery; the left si de READING
is commonly used, but the right s ide can be used if
Crowe DT (1986) Enterai nutrition for critically ill or injurcd patients.
necessary. Curved forceps are inserted into the proxi- Pans 1, II and III. Compendium of Continuing Education. Sma/1
mal cervical oesophagus via the pharynx. The tips of AnimaiS, 603-826
the forceps are then turned laterally and pressure Crowc DT and Devey JJ ( 1997) Esophagostomy tubes for fccding and
decompression: clinical experience in 29 small animal patients.
applied so the instrument can be palpated. A ski n Journal ofIlle American Animal Hospita/Association 33, 393-403
incision large enoug h to accommodate the feeding Hansficld SM ( 1990) Anaesthctie problems of the geriatrie dental
patient. Problems in Veterinary Medicine 2, 24-45
tube is made over the tips of the forceps. The forceps Muir WW Ill and Hubbell JAE (1995) Handbook of Veterinary
can be pushed through the oesophagus or, in large Anesiiiesia, 2nd edn. Mosby, St Louis
CHAPTERFOURTEEN----------------------------------

Cardiopulmonary Disease
R. Eddie Clutton

INTRODUCTION most important secondary effects are on the


heart: chronic myocardial overwork results in
Cardiopulmonary disease is freq uent! y encountered in changes s uch as hypertrophy, which impairs
companion animal practice; congenital cardiac anoma- myocardial oxygenation)
lies are not uncommon whilediminished cardiopulmo- It alters drug disposition (Figure 14.1)
nary function is a ha llmark of the ageing process. Drugs used in its treatment may interact with
Acquired cardiac disease is common in dogs and cats . anaesthetics.
lnfectious respiratory diseases are also common and
elderly animais living in urban environments may Risks from anaesthesia are reduced if:
suffer fro m the effects of air pollution. The lungs are a
common target for metastatic disease. Conditions char- An accurate diagnosis is obtained, so that the
acteri zed by chronic vomi ting are associated with low- primary (haemodynarnic) and secondary effects
grade aspiration pneumonia. lt may be necessary to of the condition are complete!y understood
anaesthetize animais with cardiopulmonary disease There is adequate preoperative preparation, i.e.
for diagnosis, for surgical correction of the condition the cardiovascular reserve is recruited
or for incidental operations. The anaesthetics used offset, rather than
As the term 'cardiopulmonary disease' encom- aggravate, the haemodynamic effects of the
passes so many conditions it is meaningless. The condition
cardiopulmonary system functions to ensure that the The adverse haemodynamic effects of surgery
rate of delivery of oxygenated blood (D02) meets or are understood and minirnized
exceeds the requirements of that of the whole body Problems of secondary complications, altered
(JÏ02) . These processes involve the combined acti vity drug behaviour and drug interactions are
of the lungs, heart and blood, and elements of the recogni zed
autonomie and somatic nervous systems that are re- A range of adjunct drugs is available to treat both
sponsible for the control of blood pressure and venti- the autonomie nervous system and
lation respectively. Th us cardiopulmonary disease can cardiovascular system
be ta ken to mean any disease that limits D02 to periph- There is adequate preoperative physiological
eral tissue, and this can involve any condition affecting monitoring.
the heart, the lungs and the oxygen-carrying capacity
and flow characteristics of blood, and the nervous Preoperative management
elements that control these processes. In this chapter,
cardiovascular disease refers to conditions affecting Preoperative examination
the heart and blood vessels, and pulmonary disease Preoperati ve examination aims to establish a diagnosis
refers to conditions affecting the airways and lung. and to predict the capacity of the cardiopulmonary
system to withstand anaesthesia and surgery. These
steps form the basis of preoperative preparation of the
CARDIOV ASCULAR DISEASE animal and the selection of appropriate anaesthetics.
No single test predicts an animal's capacity to
Problems tolerate anaesthesia and surgery; an overall picture
Cardiovascular disease increases the risks from anaes- must take into accou nt both the haemodynamic
thesia because: derangement and the significance of secondary changes.
However, the most useful index of cardiopulmonary
It increases the li kelihood of cardiopulmonary fitness - at !east in dogs - is exercise tolerance.
failure and death caused by anaesthetics A thorough review of the animal 's medical his tory
It adversely affects other organ systems (the and a physical examination may establish a diagnosis.
156 Manual of Small Animal Anaesthesia and Analgesia

Effect of disease Pharmacological significance


Reduced drug volume of distribution Greater sensitivity to injectable* anaesthetics; reduced doses
and/or infusion rates required
Slower circulation time Slower response after intravenous injection; longer wait
necessary between incrementai injections
Poor peripheral perfusion Lower drug bioavailability after intramuscular, subcutaneous
or oral drug administration
Reduced cardiac output More rapid rate of rise of alveolar concentration of inhalation
anaesthetic. Accelerated rate of induction. More rapid
response to altered vaporizer settings
Greater attention required to vaporizer settings
Reduced renal perfusion Reduced renal clearance of drugs. Metabolic acidosis
increases sensitivity to weak acidic drugs, e.g. thiopentone.
Hypoalbuminaernia increases unbound: bound drug fraction;
increased sensitivity to alburnin-bound compounds
Reduced hepatic blood flow Diminished extraction of drugs undergoing extensive hepatic
metabolism; prolonged effect
Increased ventilation/perfusion inequality S lower onset and response to altered inspired concentrations
and venous adrnixture of inhalation anaesthetic
Figure 14.1: Effects of cardiopulmonary disease on drug behaviour.
*EjJect g rem est wirh drugs g i,·en by imravenous rather thon îmramuscular or s ubcutaneous înjec1ion.

Often, more complex procedures such as radiography, tives usually increase the partial pressure of co2 in
electrocardiography, arterial blood gas analysis, ultra- arterial blood (PaC02) and may lower the partial
sonography or cardiac catheterization are required. pressure of 0 2 in arterial blood (Pa0 2).
These procedures may upset conscious animais and When tricuspid valve disease, Jow cardiac output
affect the test results or, worse, they may precipitate or passive venous congestion are present, venous
the animal's deterioration. In trying to establish a blood samples should be ta ken to evaluate hepatic and
diagnosis it may be necessary to consult a veterinary rena l function. The haematocrit, plasma haemoglobin
cardiologist. concentration ([Hb]), serum protein concentrations
Thoracic radiographs provide information on car- and plasma electrolyte concentrations (sodium [Na+],
diac chamber en largement and they assist in identify- potassium [K+] and chloride [CI-]) should also be
ing pulmonary changes. Animais in extremisshould be examined.
exarnined in the lateral decubita l position while being
supplied with oxygen. Preoperative preparation
Electrocardiography should be performed on most Preoperative preparation aims to lower risk by revers-
animais with cardiopulmonary disease (certainly ali ing the effects of pre-existing disease. The a mount of
dogs) especially when pulse irregularities are detected. preoperative preparation depends on the extent of
A cursory examination of the ECG suffices for risk dysfunction and the operation intended, but must be
assessment because arrhythmias are more important in balanced against the needs for immediate s urgery.
anaesthesia than signs of chamber enlargement or axis Elective operations must be postponed until treatment
deviation. A single lead ECG can be taken with the has achieved a 'plateau' effect and undesirable drug
animal standing orresting ifenforced recurnbency proves effects have been controlled. The primary condition is
stressful. Many sedatives are arrhythmogenic although treated first because many secondary complications
sorne, e.g. acepromazine, are anti-àrrhythmic. resolve as cardiopulmonary function improves.
Arterial blood gas analysis quantifies the ability
of the lungs to oxygenate blood, eliminate carbon Primary condition
dioxide (C02) and influence acid-base status. Al- Uncontrolled cardiac failure is a contraindication to
though equipment for blood gas analysis is rare in anaesthesia and so must be treated. Ventricular func-
veterinary practices, samples (collected anaerobi- tion is improved by:
cally and placed on ice) can us ually be analysed at
local hospital laboratories. Arterial puncture can be Using diuretics, a sodium-free diet and
stressful and may affect results by lowering co2and interventions such as pericardiocentesis to
increasing or decreasing oxygen (02 ) tension. Seda- eliminate retained fluids (Figure 14.2)
Cardiopulmonary Disease 157

Drug Indications Dose Side effects


Digoxin Heart failure Rapid i.v.: Using 250 11g/ml injectable Perioperative arrhythmias: sinus block*, AV
Atrial premature solution, prepare 10-20 j.Jg/kg. lnject block*, atrioventricular junctional rhythm,
complexes 50% i.v. and wait 30-60 minutes. Give atrial and ventricular ectopie beats and
Atrial tachycardia 25% dose i.v. and wait another 30-60 ventricular tachycardia. Anorexia. Vomiting.
Atrial fibrillation minutes before giving the final aliquot, Diarrhoea. Lethargy. Ataxia. Toxic signs occur
Sinus tachycardia if necessary. Rapid oral: Using at lower concentrations in presence of
due to heart failure tablets, 10-30 !Jg/kg is given at hypokalaemia. Toxicity enhanced by
presentation and again at 12 hours. hyperkalaemia, alkalosis, hypoxaemia,
Maintenance: 10-20 !Jg/kg divided hypercalcaemia and hypomagnesaemia. Monitor
bid electrocardiogram throughout rapid
digitalization. Any possibility that preoperative
bradycardiajbradyarrhythrnias result from
digoxin toxicity should prompt administration
of a test dose of atropine 20 !Jg/kg to ensure
that intraoperative heart rate increases are
possible
Diuretics
Loop Rapid elimination Frusemide (2-5 mg/kg every hour) i.v. Should be used only with vasodilators, i.e.
of excessive fluid rapid onset and effective in dogs and angiotensin-converting enzyme inhibitors.
cats, then 1-4 mg/kg i.m. or orally sid Hypovolaemia. Hypotension. Hypokalaemia
to tid thereafter aggravates digoxin toxicity. Metabolic
alkalosis. Hypochloraemia. Use carefully in
conditions in which cardiac output relies on
ventricular filling pressures. Monitor effect by
weight Joss
Thiazides Slow elimination Hydrochlorothiazide 2-4 mg/kg As above .
of excessive fluid orally bid
Potassium-sparing Slow elimination Spironolactone 1-2 mg/kg orally sid Plasma potassium levels unchanged
of excessive fluid or bid
Phosphodiesterase See below
inhibitors
Potassium Hypokalaemia Cats 2-6 mmol/day orally Hyperkalaemia and dysrhythmias when plasma
following Dogs 0.2-0.5 mmol/kg orally tid levels exceed 7 mmol/1. Potassium-sparing
prolonged diuretic diuretics - spironolactone, amiloride and
therapy and/or triamterene do not warrant potassium
cachexia supplementation
Figure 14.2: Drugs for preoperative preparation of animais in heart failure.
,.Sodium imake s hould be restr icted ro 10-40 m&fkg (0. 1- 0.4%) diet dry li/lifter. If possible, cases shoultl receil'e aformu/ated /ow·sodium tliet or a prescription dier.

Using digoxin, dopamine, dobutamine or disease, e.g. hyperthyroidism, phaeochromocytoma,


phosphodiesterase inhibitors to improve in which case treatment must be aimed at the inciting
myocardial contraction (see Figure 14.2) condition.
Using vasodilators, cage rest and anxiolytic
drugs to reduce cardiac work (Figure 14.3) Secondary complications
Controlling residual arrhythmias (Figure 14.4). Secondary effects of cardiopulmonary disease that are
!ife threatening, e.g. ventricular arrhythmias, need
Some arrhythmias, e.g. third degree atrioven- immediate treatment. Other secondary effects may
tricular block, arise de novo, i.e. are not secondary persist after the primary condition is treated because of
to cardiovascular disease, and are sole!y responsible irreversible damage.
for inadequate cardiac output. These are treated
with suitable anti-arrhythmic drugs or by implant- Arrhythmias
ing a pacemaker. Arrhythmias are the most important secondary com-
Cardiac failure may result from non-cardiac plication because:

.1
158 Manual of Small Animal Anaesthesia and Analgesia

Drug Indications Dose Side effects


Glyceryl trinitrate Emergency Glyceryl trinitrate 2% 0.25-2.0" Hypotension, tachycardia, azotaemia
venodilation/ (0.6-5 cm) (dogs), 0.25-0.5"
afterload reduction, (0.6-1.2 cm) (cats) bid to qid to
e.g. pulmonary medial pinna
oedema
Nitroprusside Rapid afterload Sodium nitroprusside infusion: 1-15 Hypotension, tachycardia, azotaemia. Rapid
reduction 1Jg/kg/min (dogs) effects; monitor blood pressure
Hydralazine Reduce afterload Hydralazine 0.5-3.0 mg/kg orally bid Acute: hypotension, tachycardia. Chronic:
(arteriolar dilation) (dogs) hypematraemia, hypokalaemia
e.g. acutemitral
valve regurgitation
a. 1-Antagonists Reduce afterload Prazosin (dogs <15 kg) 1 mg orally Hypotension, tachycardia, depression,
bid or tid, (dogs >15 kg) 2 mg orally weakness. Effects wane with constant use
bid or rid, 0.25-1 mg orally (cats) bid
or tid
Phenoxybenzamine 0.2-1.5 mg/kg
orally bid (dogs) 0.5-1 mg/kg orally
bid cats
Angiotensin- Non-emergency Captopril 3-6 mg/kg orally bid or tid Hypovolaemia, hypotension, tachycardia,
converting enzyme afterload control (cats) hyperkalaemia
inhibitors Enalapril 0.5-1 mg orally sid or bid May aggravate hypotensive effects of
(dogs) 0.25-0.5 mg/kg orally (cats) acepromazine (use lower acepromazine dose
Benazepril 0.25-0.5 mg/kg orally sid and prepare for crystalloid infusion)
(dogs and cats)
Phosphodiesterase Mixed effects: Propentophylline 2.5-3 mg/kg orally
inhibitors inotropy, bid (dogs)
chronotropy,
diuresis,
vasodilation
Figure 14.3: Vasodilators for preoperative preparation ofanimais in heartfailure. Vasodilators must not be usee! in:
hypotension, hypovolaemia, pre-renalfailure,jixed or dynamic obstruction of ventricularfunction, poor diastolicfimction.

Some reduce cardiac output and cause treatment instituted (see Figure 14.4). For simplicity,
hypotension. The haemodynamic significance preoperati ve arrhythmias are categorized here as
of benign arrhythmias may be increased in bradyarrhythmias (slow heart rates (HRs)) and
cardiac diseases tachyarrhythmias (fast HRs).
Untreated, benign arrhythmias may degenerate
into lethal rhythms like ventricular fibri llation Bradyarrhythmias: Preoperative bradycardia may be
(VF), asystole or electromechanical dissociation secondary to hypoglycaemia (insulinomata), hyper-
during surgery. Anaesthetists must be able to kalaemia (Addison 's disease), hypertension or hypo-
differentiate malign and benign arrhythmias from thyroidism. It may be iatrogenic (digoxin and
artefacts and be able to treat the arrhythmias ~ 1 - antagonist) or idiopathie, e.g. canine sick sinus
Spontaneously arising intraoperative arrhythmias syndrome. Bradyarrhythmias deserve investigation
indicate a deterioration in the environment of the because further slowing of the HR is li kely under
myocardium as a result of poor anaesthetic anaesthesia. At very slow HRs, myocardial blood flow
management, i.e. deranged blood gases, pH, is reduced and the heart fails.
temperature and electrolyte values. If emergency surgery is needed, the heart is tested
fi rst with atropine and then with isoprenaline to
Some arrhythmias disappear as cardiac function assess whether HR increases (see Fi.gure 14.4). A
improves. If they do persist, an alternative cause must reaction to either drug indicates the appropriate
be investigated and/or non-specifie anti-arrhythmic chronotropic treatment for control! ing intraoperati ve
Cardiopulmonary Disease 159

Drug Indications Dose Side effects


Type la Ventricular Procainamide 4-8 mg/kg over 5 Procainamide causes myocardial depression,
arrhythmias and minutes then 25-50 !Jg/kg/min hypotension and electrocardiographie
ventricular abnormalities if given rapidly
tachycardia
Malignant Quinidine 6- 10 mg/kg i.m. or Hypotension, arrhythmias
ventricular 6-20 mg/kg orally tid or qid (dogs)
arrhythmias,
refractory
supraventricular
tachycardias, acute
atrial fibrillation
Type lb Malignant Lignocaine 2-4 mg/kg i.v. then 25-75
ventricular !Jg/kg/min
arrhythmias
Type2 Tachyarrhythmias Propranolol50 !Jg/kg i.v. every 2 Hypotension, bradycardia, bronchospasm,
minutes to effect; maintenance 0.25-1 obtunded sympathetic responses to
mg/kg orally tid (dogs and cats) hypovolaemia, hypercapnia, hypoxaemia, etc.,
acute aggravation of congestive failure
Type 3 Ventricular Bretylium; effects undetermined
arrhythmias
Type4 Supraventricular Diltiazem0.5- 1.5 mg/kg orally tid Bradycardia, other arrhythmias, hypotension,
Calcium channel tachycardia, (dogs); 1.75-2.5 mg/kg orally bid or acute aggravation of congestive failure
blockers ventricular tid (cats)
tachycardia, atrial
fibrillation
Antimuscarinics Bradyarrhyihmias Atropine 20-40 !Jg/kg i.m. or s.e.
Glycopyrrolate 5-l 0 !Jg/kg i.m. or s.e.
lsopropamide 2.5-5 mg/kg orally bid
or tid
Propantheline 3.75-7.5 mg/kg orally .
bid or tid
~ 1 -Agonists Bradyarrhythmias Isoprenaline 5-10 mg ora.lly tid or
qid (dogs)
Terbutaline 1.25-5 mg/dog orally bid
or tid; 300 !Jg-1.25 mg/cal oral!y bid
or tid
Figure 14.4: Anti-arrhythmic drugs for preoperative preparation ofanimais in heart failure.

bradya rrhythmias. If neither drug increases HR, sinus rhythm, but rare!y do. Digoxin, with or without
surgery shoul d be postponed or a means of artificial ~ 1 -antagonist drugs, is nearly always required.
ventri cular pacing found.
Pulmonary oedema
Tachyarrhythmias: Preoperative tachyarrhytlunias Pulmonary oedema often indicates left heart failure
should be investigated as they compromise myocardial and occurs in severa! conditions, such as mitral valve
0 2 balance (m(D - 11)0 2) (see Figure 14.6). Unremedied incompetence, mitra l stenosis and aortic stenosis. The
m yoca rd ia l hypoxia w ill result in ventri c ular condition must be treated before anaesthesia because it
arrhythmias and eventually cardiac arrest. This is Ii kely decreases lung compliance (increases lung 'stiffness ' ),
when catecholamines are released (see F igure 14.7) . increases work of breathing and impairs oxygenation.
Vaga l manoeuvres, e.g. carotid sinus massage and It is most like ly to occur when plasma oncotic pressure
ocular pressure, are sa id to convert a trial tachycardia to is low, e.g. in hypoalbuminaemia.
160 Manual of Small Animal Anaesthesia and Analgesia

Drug class Indications Drug Precautions


Type la Ventricular Procainamide 4-8 mgjkg over 5 Procainamide causes myocardial depression,
arrhythmias and minutes then 25-50 !Jg/kg/min hypotension and electrocardiographie
ventricular abnormalities if given rapidly
tachycardia
Type lb Ma lignant Lignocaine 2-4 mg/kg i.v. then 25-75
ventricular !Jg/kg/min
arrhythmias
Type2 Tachyarrhythmias Propranolol50 !Jg/kg i.v. every 2 Hypotension, bradycardia, bronchospasm,
minutes to effect obtunded sympathetic responses to
Maintenance 0.25-1 hypovolaemia, hypercapnia, hypoxaemia, etc.,
mg/kg orally tid (dogs and cats) acute aggravation of congestive failure
Type 3 Ventricular Bretylium; effects undeterrnined
arrhythmias
Antimuscarinics Hypotension due to Atropine 20-40 !Jg/kg i.v.
slow heart rate, Glycopyrrolate 5-10 !Jg/kg i.v.
bradycardia,
bradyarrhythrnias
Negative Idiopathie Morphine 0.25-0.5 mg/kg i.v. Monitor heart rate and electrocardiogram;
chronotropes tachycardia, Alfentanil l-5 !Jg/kg every 5 minutes severe bradycardia and hypotension in
tachyarrhythmias i.v. overdose
Fentanyl l-2.5 !Jg/kg i.v. repeated
every 20 minutes or so
Digoxin 5- 10 !Jg/kg i.v.
Neostigmine 25-50 !Jg/kg i.v.
Edrophonium 1mg/kg i.v.
Figure 14.5: Anti-arrhythmic drugs used for rapid control of haemodynam ic variables during anaesthesia.

Changes in blood pH simultaneous removal ofblood and infusion of plasma,


Blood gas abnormalities caused by cardiopulmonary colloids or crystalloid solutions.
disease may in turn exacerbate the primary condition
and create self-reinforcing cycles. For example, low Right heart failure
cardiac output causes tissue hypoperfusion and meta- Right ventricular (RV) failure raises central venous
bolic acidosis. Metabolic acidosis further depresses pressure (CVP) and favours capillary transudation
cardiac contractility. Treatment should be directed at throughout the body, resulting in pleural and/or pericar-
the primary lesion, e.g. hypoperfusion, renal failure or dial effusion, ascites, hepatomegaly, splenomegaly and/
inadequate pulmonary perfusion. or peripheral oedema. Pleural and pericardial effusions
may restrict venti lation, and accumulation of pericardial
Polycythaemia fluid impedes cardiac filling (cardiac tamponade).
Polycythaemia (haematocrit > 0.55) results from any
condition that causes hypoxia, e.g. right to left intra- Renal dysfunction
pulmo nary s hunts (neoplasm, bro nchitis) o r
extrapulmonary shunts (ventricular septal defect). Hyp erkalaemia: Increased potassium concentrations
Polycythaemia increases blood viscosity and mimics are arrhythmogenic; patients should be treated with
an increased systemic vascular resistance (SVR). sodium bi carbonate solutions, calcium gluconate,
Increased SVR increases ventricular wall tension dur- insu lin - glucose solutions or cation exchange resins. In
ing systole which restricts coronary blood flow and extreme cases, peritoneal dialysis may be required.
eventually leads to ventricular failure. In peripheral
tissue, viscous blood 'sludges ' in capillaries and limits A.zotaemia: The presence of compounds containing
oxygen deli very. High haematocrit values are lowered nitrogen in the blood, along with other effects of
preoperatively by normovolaemic haemodilution - the renal fa ilure (acidaemia, hyperkalaemia), causes
Cardiopulmonary Disease 161

Factors reducing mD02 Factors increasing m V02


Low blood oxygen tension (Pa02 ) Increased heart rate
Low haemoglobin concentration Systolic wall tension, afterload
Coronary vasospasm (severe hypocaprùa) Contractility
Low arterial blood pressure Increased basal metabolic rate
Decreased heart rate
Figure 14.6: Factors ajfecting myocardial oxygen balance (m(D- V )0 2) .

Delayed drug metabolism: Hepatic dysfunction may


Conditions increasing plasma
catecholamine levels impair the rate of elimination of long-acti ng dmgs like
pentobarbitone and acepromazine.
Noxious surgical stimulation ± inadequate
anaesthesiajanalgesia Other considerations
Endotracheal intubation under ' light' anaesthesia
Hypotension Effective circulating blood volume (ECBV): Pre-
Hypoxaemia existing fluid deficits must be rectified and the over
Hypercapnia zealous use of diuretics avoided in those conditions
Hypoglycaemia in which cardiac output depends on preload.
Hyperthermia
Severe hypothermia A naemia: A haemoglobin concentration of 12- 15 g/dl
Postoperative pain is considered necessary for optimal arterial blood 0 2
E ndocdne disease content (Ca02). Below this concentration, cardiac
output increases to compensate for the anaemia. Tlùs
Hyperthyroidism increases myocardial work which, with the reduced
Phaeochromocytoma Ca02, leads to myocardial hypoxia. Low haemoglobin
Drugs concentration is resolved preoperatively by blood trans-
fusion with fresh who le blood after acute haemorrhagic
Antimuscarinics !osses, or by packed cells (haematocrit >0.65) in
P-Agorùsts chronic normovolaemic anaemia. Stored blood should
Thyroxine be transfused 24 hours befo re anaesthesia to allow any
Phosphodiesterase inhibitors abnormalities that may have occurred during storage
Figure 14.7: Factorscausing perioperative 'sympathomùnesis'. to resolve in vivo. Over transfusion must be avoided as
this increases ventricular afterload and promotes pul-
bradyarrhythmias and increases myocardial sensitiv- monary oedema.
ity to anaesthetics. Treatment depends on whether
failure is predominantly renal or prerenal. Hypokalaem ia: Low serum potassium concentrations
(caused by loop diuretics) should be increased to
Hypoalbuminaemia: Low concentrations of serum normal before surgery because hypokalaemia pre vents
albumin render animais sensitive to albumin-bound the conversion of ventricular tachycardia to sinus
dmgs like thiopentone. Low plasma oncotic pressure rhythm by anti-arrhythmic dmgs. Treatment is by
facilitates the formation of pulmonary oedema. In potassium supplementation, either orally or by the
conjunction with high CVP, hypoalbuminaemia con- infusion of crystalloid solutions ' spiked ' with potas-
tributes to peritoneal, pleural and pericardial effusions. sium chloride. T he infusion rate of potassium should
not exceed 0.5 mmolfkg/h (see Figure 14.2).
Liver dysfunction

Coagulation abnormalities: If there is any suspicion Pyrexia: Pyrexia increases cardiopulmonary activity
of impaired clotting, a coagulation test must be per- by ra ising the metabolic rate (02 andglucoseconsump-
formed. Coagulopathies are treated by the preoperative tion and C0 2 production increase). Mild hypermeta-
infusion of fresh blood - even before mi nor operations, bolism causes few problems, but the cause must be
such as dentistry. identified. Considerable risk occurs when pyrexia re-
sults from endocarditis or meningitis. Sorne antibio-
Hypoglycaemia: Glucose concentrations of 4.1 - 14.75 tics, e.g. aminoglycosides and chloramphenicol, may
mm ol/ 1 (70-2 50 mg/dl) must be esta blishe d interact adversely with anaesthetics.
perioperatively with intravenous dextrose solutions
because impaired delivery of glucose to the brain, Drugs
which is more likely with cardiovascular disease, will Drugs used to treat heart failure may produce undesir-
result in severe neuronal damage. able side effects, which complicate anaesthesia. For
162 Manual of Small Animal Anaesthesia and Analgesia

example, digoxin causes arrhythmias, and so opin- Balanced anaesthesia is more appropriate in such
ions differ over preoperative digitalization. Sorne cases and in volves using the lowest dose of anaesthetic
recommend that animais in cardiac fai lure facing capable of producing unconsciousness (which mini-
elective operations should be digitalized, but that the mizes myocardial depression) with a potent analgesie
morning dose should be withheld on the day of (to obtund reflex responses to surgery) and a muscle
surgery. Digitalized animais facing emergency op- relaxant (to improve surgical conditions). Nitrous
erations, however, should not have the drug with- oxide is frequently included because it has modest
drawn. In non-digitalized animais facing emergency cardiovascular effects and reduces the delivered
operations the infus ion of inotropes like dobutamine concentration of inhalant drug required to produce a
may be as effective (and less hazardous) than rapid given levet of anaesthesia. Balanced anaesthesia is not
intravenous digitalization . without complications; neuromuscular blocking agents
As a rule, attempting to limit potential interactions eliminate both respiration and the most obvious sign of
by withdrawing drugs before anaesthesia may cause inadequate anaesthesia - movement.
more problems than it solves. The fear of interactions
should not be used as an excuse for inadequate prepa- Dmg selection
ration. Ideal!y, surgery should be postponed until treat- Selecting the most appropriate anaesthetic for a par-
ment has achieved a maximal effect, and drug side ticular animal is simplified by categorizing acquired
effects have been minimized. cardiovascular diseases (see Figure 14.8). As a rule,
the anaesthetics chosen s hould have minimal effect on
Anaesthetic techniques myocardial contractility and peripheral venous tone.
In addition to providing adequate conditions for sur-
Options gery (analgesia and muscle relaxation), the anaesthetic
Major surgery can be performed undersedation (which chosen should:
keeps the animal still) and local anaesthesia, provid-
ing the surgical site is amenable to local teclmiques. Reverse the haemodynamic disorder by
Sedation or anaesthesia may be req uired for sorne mirnicking the effects of medical treatment (this
tests . The assumption that sedatives are safer than requires a knowledge of drug effects, which are
genera l anaesthesia seems intuitive, and administra- sunm1arized in Figure 14.9)
tion more straightforward. However, sedatives may Be compatible with drugs used perioperatively to
be unpredictable, provide an inadequate duration of improve cardiovascular function
effect, cause adverse physiological effects and fait to Be suitable in the presence of secondary cerebral,
provide conditions for both invasive physiological myocardial, hepatic or renal complications
measurement and the support of ventilation. In con- Be minimally affected by altered
trast, general anaesthesia allows tracheal intubation pharmacokinetics.
so that intermittent positive-pressure ventilation
(IPPV) is possible. The leve! of anaesthesia can be Identifying an ideal technique is difficult because
adjusted to suit the investigation at any moment. of a paucity of data on anaesthetic behaviour in
General anaesthesia with volatil e agents provides companion animais with cardiopulmonary disease.
rapid recoveri es after prolonged inves tigations The data s ummarized in Figure 14.9 are simplistic
becau se their e limin ation is inde pendent of and imply th at drug behaviour is independent of other
cardiac, hepatic and renal fu nction. variables. It is not, and an obsession with drug s uit-
Local anaesthetic injected into the spinal or extra- ability based on theoretical haemodynamic effects
durai space can, under certain circumstances, cause diverts attention from other perioperative factors
catastrophic haemodynamic effects. exacerbating cardiopulmonary derangement. In any
Pre-anaesthetic medication with a neuroleptan- case, the adverse haemodynamic effect of an anaes-
algesic combination such as acepromazine and thetic can easily be negated. For example, the myo-
butorphanol, induction with an ultra-shot1-acting in- cardial depressant effect of halothane is reversed by
jectable anaesthetic such as propofol, and light general infusing fluids and/or infusing inotropes.
anaesthesia produced with halothane (and possibly The assumption that new anaesthetics are safer
nitrous oxide (N20)) provide adequate conditions for than the older .agents for animais with cardiopulmo-
minor operations in an imais with modest cardiac dis- nary disease is rnisconceived and dangerous. Drugs
ease, providing attention is paid to ventilation, tem- often behave differently in animais with cardiovascu-
perature, circulating blood volume and perioperative lar disease, and so when using unfamiliar drugs it is
analgesia. This technique is, however, inadequate in difficult to determine if an undesirable effect is normal
animais with advanced disease undergoing major op- or indicates deteriorating conditions. Allegedly safer
erations because it does not prevent the autonomie anaesthetics provide a temptation to anaesthetize those
nervous responses to noxious (surgical) stimulation animais that would previously have been regarded as
which adversely affect cardiovascular function. unacceptable risks. Under these circumstances the use
Cardiopulmonary Disease 163

of unfamiliar drugs (which are unlikely to be safer) in tion, venepuncture or mask induction to be conducted
susceptible ani mais may have dire consequences. without stress to the ani mal. Neuroleptanalgesic com-
Ultimately, anaesthetic risk depends as much on the binations based on low-dose acepromazine and opioids
anaesthetist 's experience with an agent as it does on the are useful in dogs and cats. The opioid chosen depends
drug 's calculated lethality (therapeutic index), and so on severa! factors including its haemodynamic effects .
it is better to choose any fundamentally safe, and For example, the author fa vours morphine, except
familiar, teclmique over one that may in theory be when braclycardia is undesirable, when pentazocine or
more appropriate but which is unfamiliar. pethicline are used instead. Neuroleptanalgesic combi-
nations are sa fe in cats: morphine 0.1- 0.25 mg/kg does
Pre-anaesthetic medication not produce undesirable neurological effects provided
Pre-anaesthetic medication should alleviate an ani- it is injected intramuscu larly with acepromazine
mal 's anxiety and pain, and ena ble venous catheteriza- 0.05- 0. 1 mg/kg.

Category Example Problems Management goals


High cardiac output Secondary to hypermetabolic Slow induction to anaesthesia Avoid increases in heart rate
conditions: hyperthyroidism; with volatile agents. Increased Suppress myocardial
phaeochromocytoma; risk of myocardial hypoxia, contractility
hypercapnia arrhythmias. High output failure Suppress afterload
in response to catecholamines Avoid catecholamine release
Low cardiac output
Fixed Obstructive Mitral and aortic regurgitation Heart rate unable to increase Maintain or increase heart rate
(valvular) and stenosis, pulmonary output in response to challenge. (not >20%resting)
hypertension Intolerant of any changes Maintain sinus rhythm
Cardiac tamponade affecting cardiac output. Avoid falls in systemic
Fixed heart rate Canine sick sinus syndrome Increased systemic vascular vascular resistance
Ventricular Cardiomyopathy resistance (SVR) causes Avoid myocardial depression/
'End stage' heart disease hypertension;more importantly, maintain contractility
reduced systemic vascular Avoid myocardial ischaemia
resistance, venomotor tone or Maintain preload
heart rate causes marked
hypotension
Variable Inefficient heart Ventricular tachycardia Myocardial hypoxia, Reduce heart rate and
rate hypotension variables decreasing
myocardial oxygen balance
(m(D-li)0 2)
Hypothyroidism Myocardial hypoxia, Increase heart rate
hypotension
Inadequate Cardiomyopathy Myocardial hypoxia, Maintain contractility
contractility hypotension
'End stage' heart disease Minimize variables decreasing
myocardial oxygen balance
(m(D- li)02)
Inadequate preload Hypovolaemia, septicaemia Hypotension Maintain preload
Increase systemic vascular
resistance
Avoid high inflation pressures
during positive-pressure
ventilation
Excessive afterload Polycythaemia, hypertension, Myocardial hypoxia, Decrease systemic vascular
cor pulmonale arrhythmias, end organ damage resistance
in brain, eyes, heart, kidney
and arteries
Figure 14.8: Classification of cardiac jailure.
164 Manual of Small Animal Anaesthesia and Analgesia

Drug Cardiac Inotropy Heart Systemic Mean Pulmonary Central Electrocardiogram


output rate vascular arterial vascular venous
(QJ resistance pressure resistance pressure
Acepromazine ·->! .... .... ! !! ! ? ! Type lb anti-arrhythmic effect,
may cause some slowing, first
degree atrioventricular black
Diazepam .... .... .... .... ! .... ? ....
Midazolam .... ! ·-+! .... t ? .... ! ? ?
Morphine* .... .... ! ! .... ? u Bradycardia, bradyarrhythmias,
though tachycardiafhypotension
(histamine release) may follow
rapid i. v. injection of any opioid
Pethidine .... ! .... ! t .... ! ! ? t
Butorphanol .... .... ·-+! .... .... ! ? ?
Buprenorphlne .... .... .... ! .... +-+ ! ? ?
Atropine t .... ttt .... +-+t ? ? Tachycardia, ventricular
arrhythmias
~-Agonists ! .... !!! t-! t-! ? ? Bradycardia, first or second degree
atrioventricular block.. Xylazine
may 'sensitize' myocardium to
catecholamines
Thiopentone ! .... ! tt .... ! ! ? ! Occasionally causes transient
ventricular arrhythmias
Alphaxalone/ ! ! tt ! ! t !
alphadolone
Ketamine tt it t t it ? ?
Propofol ! ! .... ! ? ! ? ?
Halothane !! !! +-+! .... ! +-+! t 'Sensitizes' myocardium to
catecholamines
Isoflurane .... t +-+! t !! !! +-+! t
Ni trous oxide +-+t ! t .... +-+t t ....
Desflurane t .... ! t !! !! .... ! t
Sevoflurane .... t .... ! .... ! ! ! ?
Fentanyl ·-+! .... !! .... ....! ? .... Bradycardia, bradyarrhythmias
(negated by co-injection of
atropine)
Alfentanil .... ! .... !! .... .... ! ? .... Bradycardia, bradyarrhythmias
(negated by co-injection of
atropine)
Figure 14.. 9: Summary of the haemodynamic effects ofsedatives and anaesthetics. Data have been derived from several species
and sources. Drug effects will be injluenced by physiological, pathological and pharmacologicalfactors unique to individual
patients, so under certain conditions minimal or even opposite changes to those described may be seen.
• Notr..Weroidal anti·itiflammatory drugs e.g. carprofett. ketoprofen. han! nol been included in titis list because of minimal direct lwemodynamic ef!ects.
1, increased; l, decreased; -. 110 change; - l , none. OR. slighrly decreasetl effect; 1-1, biplwsic effect; '!, f/O informationfotmd.

Diazepam- or midazolam-based combinations of- tion even in depressed animais . They are useful in cats
fer theoretical benefits because benzodiazepines are when combined with ketamine and/or acepromazine.
largely devoid of cardiovascular effect. They are, Medetomidine should not be used for pre-anaes-
however, unreliable sedatives and often cause stimula- thetic medication in ill animais. The availability of an
Carcliopulmonary Disease 165

antagonist does not justify the use of medetomidine or Induction by mask or by the combination of mask
other ~-agonists in high risk cases given the wide- with subanaesthetic doses of intravenous agents (in-
spread cardiovascular disturbances they cause. cluding alphaxolonejalphadolone 3 mg/kg) is feasible
Antimuscarinic drugs (atropine and glycopyrrolate) in well sedated cats . Providing the animal is sedated,
may be required if bradycardia is present or likely to induction by chamber is preferable because it avoids
develop. They should not be used routine! y as they can the stress of restraint.
cause arrhythmias, especially in animais whose myo- Transient ventricular arrhythmias are not uncom-
cardial oxygen balance is precarious. There seems to mon during induction. The incidence seems to be
be little evidence for the belief that glycopyrrolate is reduced if intravenous anaesthetic solutions are di-
safer than atropine in this respect. luted, e.g. 1.25 % thiopentone, and injected slowly.
Severely debilitated animais should not be left Nevertheless, syringes prefilled with rapidly acti ng
unattended once pre-anaesthetic medication has been anti-arrhythmic drugs, such as lignocaine (lidocaine)
given, and there are advantages in applying the ECG and atropine, should be available and the ECG moni-
and other physiological monitors, which the patient tored throughout.
will tolerate, at this stage. In very poorly animais, the Postinduction apnoea is normal with intravenous
insertion of central verrous and/or arterial catheters anaesthetics, especially propofol, and may cause
under local anaesthesia may be possible. Enriching haemoglobin desaturation. Apnoea after normal
inspired air with 0 2 will rare! y do harm at this stage. doses, however, is inconsequential providing the
This can be achieved in severa! ways if the direct trachea is intubated promptly and the lungs inflated
application of a mask is resented. thereafter with 0 2-enriched gas, at a rate of 2-3
breaths per minute.
Induction
Induction of anaesthesia must be stress free and not Maintenance
unduly compromise haemodynamic function. Induc- Anaesthesia should provide surgical conditions using
tion enables atraumatic intubation of the trachea drugs thatarenon-cumulativeand th at preservecardio-
using a minimum effective dose (MED) of anaes- pulmonary function. Volatile anaesthetics have a
thetic. Anaesthesia must, however, be adequate for profoundly depressant ef