PRESENTATION
BROCHURE
Manual of ANAESTHETIC MONITORING
IN SMALL ANIMALS Manual of ANAESTHETIC MONITORING IN SMALL ANIMALS
Ignacio Sández Cordero
IN SMALL ANIMALS
eBook
Manual of ANAESTHETIC MONITORING IN SMALL ANIMALS
Manual of Anaesthetic Monitoring in Small Animals
Manual of ANAESTHETIC MONITORING
Ignacio Sández Cordero
included
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This practical book explains how to monitor the organ systems of healthy and medically compromised patients during anaesthesia so as to help veterinary surgeons understand what is happening at every moment and reduce complications. In addition, it has been conceived as a reference book that can be consulted in emergency situations. The authors, who are specialists in the field, provide in-depth information about the physiological aspects of anaesthesia, together with numerous clinical cases and real situations.
Author IGNACIO SÁNDEZ CORDERO Coordinator of the Anaesthesiology Service at Sinergia Veterinaria (Madrid).
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TARGET AUDIENCE:
✱ Small animal vets. Anaesthesia ✱ Veterinary nurses ✱ Veterinary students RETAIL PRICE FORMAT: 17 × 24 cm NUMBER OF PAGES: 192 NUMBER OF IMAGES: 102 BINDING: hardcover ISBN: 978-84-18339-58-5 PUBLISHING DATE: December 2020
74 €
COLLABORATORS Miguel Ángel Cabezas Salamanca Miguel Martínez Fernández Fernando Martínez Taboada María Soto Martín Daniel Torralbo del Moral Manuel Martín Flores Jerónimo Martínez Pino
Eva Rioja García J. Ignacio Redondo García Francesco Aprea Jaime Viscasillas Monteagudo Carolina Palacios Jiménez Matias Lorenzutti
KEY FEATURES:
➜ A llows clinicians to better understand surgical monitors and to make the most of every measured parameter. ➜ Covers the monitoring of the different organ systems. ➜ Includes numerous clinical cases and real situations. ➜ A reference book that can be consulted in emergency situations.
Manual of Anaesthetic Monitoring in Small Animals
Presentation of the book The objective of this book is to help veterinary surgeons understand what is happening during anaesthesia so they can anticipate potential complications and, above all, update their knowledge in one of the areas of veterinary anaesthesia where most advances have been made in recent years. This book addresses anaesthesia in critical and high-risk patients as well as healthy ones because on many occasions critical patients are actually identified through monitoring, and a healthy patient can become critical in just a few minutes.
Anaesthetic monitoring neither starts nor ends with the surgical procedure. An adequate assessment must be performed before undergoing anaesthesia so as to recognise critical points during the perianaesthetic period. Patients may also need intensive postoperative care, which can even be more complex than the surgery itself, so appropriately monitoring these patients during the postanaesthetic period is crucial. Consequently, all these topics are also addressed in several chapters. This book will allow clinicians to better understand surgical monitors and to make the most of every measured parameter.
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This book covers the monitoring of the different organ systems. Regarding the cardiovascular system, it ranges from electrocardiogram monitoring to the latest advances in cardiac output monitoring, including arterial pressure assessment. As to the respiratory system, it provides information about pulse oximetry and its curve, capnography and capnogram interpretation, and monitoring respiratory mechanics in patients on mechanical ventilation, including the analysis of all its curves and loops. This book vastly covers the nervous system for veterinary surgeons to make the most of the available visual monitoring methods and of the new monitors that use electroencephalography to assess hypnotic depth. Other types of monitoring are also addressed, such as temperature management and hypothermia prevention, arterial blood gases and how they can improve ventilation, and other analytical parameters such as lactate, electrolytes, etc.
The author Ignacio Sández Cordero Ignacio Sández Cordero graduated in veterinary medicine at the Complutense University of Madrid, Spain, in 2000. He is certified in anaesthesia and analgesia by AVEPA (Spanish Small Animal Veterinary Association). He has coordinated the Anaesthesiology Service at Sinergia Veterinaria (Madrid) since its creation. Sinergia Veterinaria provides referral services to more than 80 veterinary clinics and hospitals. He is also a founding member of the Spanish Society of Anaesthesia and Analgesia (SEAAV) and was part of the board of directors from its creation to June 2012. Since 2005 he has taught courses, workshops and online courses on anaesthesia both in Spain and abroad, and he has participated as a speaker at several SEAAV and AVA (Association of Veterinary Anaesthetists) congresses. Author of more than 20 articles on small animal anaesthesia, analgesia and resuscitation published in Spanish journals and online journals with international reach, he has also authored the book Manual clínico de farmacología y complicaciones en anestesia de pequeños animales (Clinical Manual of Small Animal Pharmacology and Anaesthetic Complications).
Collaborators Miguel Ángel Cabezas Salamanca Degree in veterinary medicine. Certified in anaesthesia and analgesia by AVEPA. Head of the Anaesthesia and Resuscitation Service at the Puchol veterinary hospital in Madrid. Member of SEAAV, AVA, the International Association for the Study of Pain (IASP), and the International Veterinary Academy of Pain Management (IVAPM).
Miguel Martínez Fernández Degree in veterinary medicine. European Diplomate in Veterinary Anaesthesia and Analgesia. President of the SEAAV. Head of the Anaesthesiology Service at Chestergates Veterinary Specialists, UK. Member of SEAAV and AVA.
Fernando Martínez Taboada Degree in veterinary medicine. European Diplomate in Veterinary Anaesthesia and Analgesia. Head of the Veterinary Anaesthesia and Analgesia Service at the School of Veterinary Science of the University of Sydney, Australia. Member of SEAAV and AVA.
María Soto Martín Degree in veterinary medicine. Member of the Anaesthesiology Service at Sinergia Veterinaria, Madrid. Member of SEAAV and of the AVEPA Working Group on Anaesthesia (GAVA).
Daniel Torralbo del Moral Degree in veterinary medicine. AVEPA-certified in anaesthesia and analgesia. Member of the Anaesthesiology Service at Sinergia Veterinaria, Madrid. Member of SEAAV and GAVA.
Manual of Anaesthetic Monitoring in Small Animals
Manuel Martín Flores Degree in veterinary medicine. American Diplomate in Anaesthesia and Analgesia. Assistant professor in the Anaesthesiology Service of the Department of Clinical Sciences at the Cornell University College of Veterinary Medicine, USA. Member of the American College of Veterinary Anaesthesia and Analgesia (ACVAA).
Jerónimo Martínez Pino Degree in veterinary medicine. AVEPA-certified in anaesthesia and analgesia. Head of the Anaesthesia and Resuscitation Service at the Neurología Veterinaria veterinary centre in Madrid. Member of SEAAV and GAVA.
Eva Rioja García Degree and a PhD in veterinary medicine. American Diplomate in Anaesthesia and Analgesia. Head of the Anaesthesia Service at the North West Veterinary Surgeons Hospital, UK. Member of SEAAV, AVA and ACVAA.
J. Ignacio Redondo García Anaesthesiologist at the Veterinary Teaching Hospital of the University CEU Cardenal Herrera of Valencia. Member of SEAAV, AVA, GAVA, and the Association of Veterinary Anaesthesiology of the Argentine Republic (AAVRA).
Francesco Aprea Degree in veterinary medicine. European Diplomate in Veterinary Anaesthesia and Analgesia. Head of SAAVET, a Veterinary Anaesthesia and Analgesia Service in Majorca (Spain) and the UK. Member of the Credential and Education Committee of the European College of Anaesthesia. Member of SEAAV and AVA.
Jaime Viscasillas Monteagudo Degree in veterinary medicine. European Diplomate in Veterinary Anaesthesia and Analgesia. AVEPA-certified in anaesthesia and analgesia. Professor of anaesthesia and analgesia at the Royal Veterinary College in London, UK. Member of SEAAV, of AVA, and of the Anaesthesia and Analgesia Service at the Royal Veterinary College.
Carolina Palacios Jiménez Degree and a PhD in veterinary medicine. European Diplomate in Veterinary Anaesthesia and Analgesia. Professor of anaesthesia and analgesia at the Royal Veterinary College in London, UK. She is a member of SEAAV, AVA, and the Anaesthesia and Analgesia Service at the Royal Veterinary College.
Matias Lorenzutti Degree and a PhD in veterinary medicine. Associate professor at the Universidad Católica de Córdoba, Argentina. Head of the Anaesthesiology Service at the veterinary hospital of the same university and of the National University of Villa María. Member of AAVRA.
Table of contents 1. Monitoring and complications in the perianaesthetic period Introduction Objectives of monitoring during anaesthesia Frequent complications and mortality during the perianaesthetic period Adequate monitoring for each anaesthetic procedure
2. Assessment and pre-anaesthesia consultation Introduction Pre-anaesthesia consultation Anaesthetic risk
3. Anaesthesia record Introduction Anaesthetic monitoring sheet Optimisation of the anaesthesia record Post-operative monitoring sheet Monitoring sheet for sedation Checklists
4. Basic examination of the patient during the perianaesthetic period Introduction Evaluation of body condition (BC) Auscultation Cardiac auscultation Peripheral pulse palpation Mucosal colour Capillary refill time
5. Cardiovascular system monitoring Introduction Electrocardiogram (ECG) Blood pressure Central venous pressure (CVP) Oxygen delivery to tissues Monitoring of preload status
6. Respiratory system monitoring Pulse oximetry Capnography
7. Mechanical ventilation monitoring Introduction Physiology of spontaneous ventilation Monitoring of ventilatory mechanics Compliance and resistance Evaluation of the ventilation/perfusion (V/Q) ratio Evaluation of alveolar collapse or pulmonary atelectasis in anaesthesia Impact of mechanical ventilation on the cardiovascular system
8. Monitoring of temperature. Hypothermia and hyperthermia Physiology of thermoregulation Temperature monitoring
9. Nervous system monitoring during anaesthesia Introduction Evaluation of the degree of hypnosis Evaluation of the degree of intraoperative analgesia Additional monitoring of the nervous system: intracranial pressure (ICP) monitoring
10. Monitoring of neuromuscular function Introduction Principles of neuromuscular monitoring Reversal of neuromuscular block
11. Arterial and venous blood gas analysis Introduction Acid-base imbalances Alveolar-arterial CO2 difference
12. Lactate Lactate production Lactate removal Use of lactate during stress Measurement of lactate levels Interpretation of lactate values Prognostic and diagnostic value of lactate
13. Post-anaesthetic monitoring of the critically ill patient Introduction Cardiovascular system Respiratory system Urine production Blood tests Temperature Analgesia Pain assessment/monitoring Use of analgesics Other considerations Glasgow Feline Composite Measure Pain Score: CMPS Glasgow Canine Composite Measure Pain Score: CMPS
14. Bibliography
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+34 976 461 480
Manual of ANAESTHETIC MONITORING
IN SMALL ANIMALS Manual of ANAESTHETIC MONITORING IN SMALL ANIMALS
Ignacio Sández Cordero
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EVALUATION OF THE DEGREE OF HYPNOSIS
Eyeball position and reflexes The position of the eyeball is usually a good indicator of the plane of hypnosis, especially in dogs (Fig. 1). Some drugs such as ketamine and neuromuscular blockers can cause the eyeball to focus, making it difficult to assess the plane of hypnosis. The eyelid reflex can also be assessed to evaluate the degree of hypnosis. Because the corneal reflex may or may not be present in the medium-to-deep plane of hypnosis, its assessment is not very useful. In cats, the palpebral reflex can be substituted with the atrial reflex, which indicates the same depth of hypnosis.
The presence of a palpebral reflex during anaesthesia is indicative of a superficial plane of hypnosis.
HYPNOTIC DRUG DOSE
DEGREE OF UNCONSCIOUSNESS
Depth of hypnosis has traditionally been assessed using a series of clinical parameters such as blood pressure, heart rate, respiratory pattern, movement, and pupillary reflexes. While all these parameters change with the depth of the hypnotic state, they are still associated with the response of the autonomic nervous system (ANS) to stimuli and are poor markers of CNS depression. Consequently, they are not always modified when the plane of hypnosis becomes shallower or deeper. Furthermore, the use of certain drugs (e.g. neuromuscular blockers, α2 agonists) may mask some of these signs.
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> FIGURE 1. Rotation of the eyeball and pupillary dilation depending on the plane of hypnosis.
Concentration of anaesthetic agents In current veterinary anaesthesia the most widely used hypnotics are inhalation anaesthetics (isoflurane, sevoflurane). Numerous studies have determined the alveolar concentrations of each anaesthetic capable of producing unconsciousness or abolishing the sympathetic response in various species
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(Steffey and Howland, 1977). However, these concentrations are not usually determined under laboratory conditions, and therefore may not be valid in the clinical setting. Moreover, most of these values are statistical values, which can undergo variations between individuals. Finally, multiple situations can modify the concentration of inhalation anaesthetic required to produce a hypnotic effect, including the use of opioids, use of benzodiazepines, age, temperature, and electrolyte imbalances. In reality, the minimum alveolar concentration (MAC) of an anaesthetic should be viewed as an indictor of its potency, and can therefore be used to guide the initial dosage of the drug in a patient. However, the exact dose of a given inhalation agent should be determined individually for each patient prior to administration (Fig. 2). In any case, by knowing the percentage of halogenated agent exhaled by the patient, changes to the plane of hypnosis can be made more safely, avoiding overdosing or underdosing.
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Evaluation of the electrical activity of the brain: electroencephalogram (EEG) EEG wave analysis can reveal the state of consciousness or alertness of the cerebral cortex. Alert or conscious states are characterised by a predominance of low-voltage and high-frequency waves, whereas high-voltage and low-frequency waves predominate in unconscious states. When the latter are very deep, periods of “cortical silence” with no brain activity may be observed. This is known as burst suppression. Collection of all these data can provide very accurate information on the plane of hypnosis and the response capacity of the cerebral cortex. However, this analysis requires complex equipment and, above all, a very high degree of knowledge and specialisation in electro-neurophysiology, and is therefore not viable in most small animal clinics. Recent years have seen the development of monitors that display new parameters, including evoked potentials, entropy, and the bispectral index (BIS), and facilitate EEG analysis for
FIGURE 2. Inspired and expired fraction of anaesthetic gases.
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anaesthesiologists. BIS is considered the gold standard in human medicine for monitoring consciousness, based on the results of several published studies and its ease of use for clinical anaesthesiologists (Rampil, 1998). BIS is a dimensionless number that ranges from 0 to 100 (Fig. 3). In humans, values >90 indicate a conscious patient, and values of 70–90 indicate light-to-deep sedation. Explicit memory is abolished at values <70, and implicit memory at values <60. The indicated range to maintain unconsciousness is between 60 and 40. Values <40 are indicative of overdosing, unless a barbiturate coma is desired, which is characterised by values <20 and burst suppression >50 %. Zero value indicates EEG suppression (not brain death, but flat EEG).
It should be taken into account that the BIS does not monitor the anaesthetic dose, but rather the metabolic state of the brain, regardless of the cause that is modifying it (drugs, hypoglycaemia, cerebral oedema, cerebral perfusion, etc.).
BIS has been used in veterinary medicine for research purposes, but adequate clinical validation has not yet been performed (Brás et al., 2014; March and Muir, 2005). Furthermore, the results of studies using BIS to monitor the state of consciousness are
FIGURE 3. Bispectral index (BIS) monitoring during anaesthesia. The BIS value is displayed in the upper left box. To the right on the screen are the signal quality index (ICS in Spanish), muscle activity or electromyogram (EMG), and a continuous electroencephalogram (EEG) trace. The upper right box shows the percentage of burst suppression (TS in Spanish). The evolution of the BIS value throughout the entire anaesthesia period is shown in the lower part of the screen.
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controversial. In cats there appears to be no exact correlation between the BIS value and the depth of hypnosis, and therefore it should not be used as the sole method to guide the dosage of hypnotic anaesthetics (Lamont et al., 2004; March and Muir, 2003). In dogs, several studies have concluded that BIS is a good indicator of the plane of hypnosis (Bleijenberg et al., 2011; Campagnol et al., 2007; Lopes et al., 2008). A technical limitation arises in clinical practice due to the fact that this monitor’s sensors are designed for placement in the frontotemporal region of a human head using adhesive electrodes, which are very large for small animals (Fig. 4). Low impedance, fine-needle electrodes can be used on animals of any size, without the need to shave the hair on the head (Greene et al., 2002) (Fig. 5). BIS values in the range of 40–70 are compatible with an appropriate plane of hypnosis for surgery in dogs, but should always be interpreted in combination with other visual monitoring data (reflexes and eyeball position).
EVALUATION OF THE DEGREE OF INTRAOPERATIVE ANALGESIA Pain during general anaesthesia is very difficult to assess: because it is not possible to measure the responsiveness of the cerebral cortex, it is difficult to know whether the surgical stimulus is painful. In fact, by definition an animal in an appropriate plane of hypnosis cannot feel pain, as pain is a conscious sensation. What
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FIGURE 4. Placement of bispectral index (BIS) electrodes on a dog after shaving the hair on the head. Image courtesy of Jerónimo Martínez.
is often observed in patients during surgery is a sympathetic response to a nociceptive stimulus (tachycardia and hypertension), but not pain. It is important to differentiate these phenomena, since the corresponding treatment differs in each case. There is not yet any monitoring method that can reliably assess the degree of analgesia during anaesthesia, although methods are being developed to assess parameters related to the degree of analgesia. These include changes in the electrical conductivity of the skin, electrocardiogram changes, plethysmography parameters, changes in cardiovascular parameters (blood pressure and heart rate), and the integration of several of these parameters into the same monitor.
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FIGURE 5. Adaptation of bispectral index (BIS) electrodes with low impedance needles to improve contact without shaving the hair on the head.
Blood pressure (BP) and heart rate (HR) These two variables are the most widely used nowadays to assess the degree of intraoperative nociception. A sufficiently powerful surgical stimulus can trigger a sympathetic response and this, within a few seconds, produces an increase in HR and/or BP (Cowen et al., 2015). The two variables will not necessarily increase at the same time, since certain stimuli will only produce an increase in either HR or BP. These changes can occur due to many factors, and therefore are very sensitive indicators, albeit not very specific for the diagnosis of nociception. The underlying cause of the change should be sought, and then treatment (analgesia) administered only if these changes persist over time (>1–2 minutes) and if the increases are significant (>20 %).
Plethysmographic curve The pulse oximeter, in addition to showing haemoglobin saturation, provides a graphical representation of changes in tissue size (plethysmography). When a pulse oximetry probe is placed in the peripheral tissues, changes in the peripheral vessels can be assessed. Vasoconstriction or vasodilation can be seen on the plethysmographic curve very quickly. A sympathetic response to a nociceptive stimulus usually results in release of catecholamines, which cause marked peripheral vasoconstriction and rapid changes in the plethysmography curve, which becomes narrower (Fig. 6).
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Parasympathetic tone activity (PTA) A monitor has been developed to evaluate nociception during anaesthesia, with a specific algorithm for dogs, cats, and horses (PTA index). This monitor evaluates the parasympathetic tone by means of the electrocardiogram (ECG), and calculates the interval between R waves, which is expressed as a number between 0 and 100 (Fig. 7). A value of 100 indicates a predominance of parasympathetic
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over sympathetic tone, and therefore an absence of nociception or sympathetic response to a nociceptive stimulus. While very few veterinary studies have shown that PTA is capable of predicting the sympathetic response before heart rate or blood pressure (Mansour et al., 2017), it may be helpful in evaluating the intensity of the response, and thus could facilitate the administration of analgesics at the right dose and the right time.
FIGURE 6. Narrowing of the plethysmographic curve due to peripheral vasoconstriction (sympathetic response).
FIGURE 7. Parasympathetic tone activity (PTA) monitor in a cat during general anaesthesia.
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Changes in BIS The absolute value of BIS provides an indication of the patient’s level of consciousness. This cortical state is also dependent on the level of stimulation received. Thus, the variability of BIS over time is associated with states of high stimulation (nociception). The greater the variability of the patient’s BIS, the poorer the control of surgical stimuli. Therefore, although the BIS monitor is not a “pain” monitor, it can indirectly help with the titration of analgesic drugs, and will show cortical reactivity in response to painful stimuli during surgery (Fig. 8). The phenomenon of “paradoxical awakening” after nociceptive stimulation is described in BIS monitoring of humans and experimental animals (Otto and Mally, 2003).
ADDITIONAL MONITORING OF THE NERVOUS SYSTEM: INTRACRANIAL PRESSURE (ICP) MONITORING The importance of monitoring ICP in neurocritical patients is due to the fact that increased ICP opposes the intrinsic force of mean arterial pressure (MAP) to ensure correct cerebral perfusion pressure (CPP): CPP= MAP-ICP (You et al., 2016). An altered CPP leads to a loss of autoregulation of cerebral blood flow, resulting in hypoxia and cerebral ischaemia. An increase in ICP can also cause herniation of some brain regions, leading to ischaemia or compression of the brain stem.
FIGURE 8. Bispectral index (BIS) monitoring in a dog with an epidural block. The BIS value remains very constant due to the absence of nociceptive stimuli, despite the slightly superficial plane of hypnosis.
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The following are the most frequent causes of intracranial hypertension (ICH) that may require general anaesthesia, and in which ICP monitoring may be indicated: ■ Cranioencephalic trauma ■ Tumours ■ Hydrocephalus. Although there are some noninvasive methods for monitoring ICP in human medicine, these are not well described in veterinary medicine (transcranial Doppler).
Monitoring of ICP using an intraventricular catheter is an invasive technique and currently the gold standard for monitoring ICP in human medicine.
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This technique is not described in veterinary medicine. A measurement can be taken by placing a needle in the cerebral ventricles (Fig. 9), in the cisterna magna, or in the subarachnoid space. This needle is connected to a (blood) pressure transducer via a rigid serum line, which in turn is connected to the multi-parameter monitor via an invasive blood pressure transducer. The monitor will show the invasive pressure trace, in addition to a numerical ICP value, and an ICP curve, which is made up of 3 curves: P1, P2, and P3 (Fig. 10). P1 represents the arterial wave (percussion) of the blood in the choroid plexuses; P2 is the rebound (or tidal) wave; and P3 represents venous outflow (dicrotic wave). A normal ICP in dogs and cats should be below 10–15 mmHg (Fig. 11).
FIGURE 9. Intracranial pressure measurement using an invasive blood pressure transducer placed at the level of the skull, attached to a serum line and connected to a needle inserted directly into the ventricle.
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FIGURE 10. Intracranial pressure (ICP) curve during direct monitoring. P1
Normal ICP
Pressure
P2
P3
Duration
Pressure
P2
Increased ICP
P3
P1
Duration P1: Percussion (arterial)
P2: Tidal (rebound)
P3: Dicrotic (venous)
FIGURE 11. Intracranial pressure monitoring during anaesthesia in a dog with hydrocephalus and intracranial hypertension.
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