Thomas Heckel, LVT Surgery Department This session will help you to evaluate a patient’s preanesthetic workup and formulate an anesthetic protocol. We will review how patient comorbidities and body system functions influence anesthetic choices.

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THE ANESTHETIC PROTOCOL
Thomas Heckel LVT
Upstate Veterinary Specialists
10/16/20182018 FALL CE | THE ANESTHETIC PROTOCOL

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Essential for successful anesthesia management.
1. Pre-anesthetic
2. Peri-anesthetic
3. Post-anesthetic
PRE-ANESTHETIC WORKUP
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 Signalment
 Age, Breed, Species, Sex
 Client Information
 Emergency Contact
 Different Species have different special
considerations
 Metabolic Requirements vary
 Influences dosage
 Breed Specifics
 Sight Hounds
 Brachycephalic
 Boxers
 Miniature Schnauzers
 Doberman Pinchers
 Gender
 Age
 Behavior
 Preexisting Conditions
INFLUENCING FACTORS
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 Feline patients
 Tend to develop laryngospasm during
intubation
 Not common in canines
 Sighthounds
 Little to no body fat
 Alteration of liver enzymes
 Impact metabolism and redistribution of
drugs  Prolonged Recovery
 Brachycephalic
 Upper Airway obstruction syndrome
 Dogs and Cats
SPECIES CONSIDERATIONS
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 Boxers
 Acepromazine
 Mini Schnauzers
 Sick Sinus Syndrome
 Doberman
 von Willebrands
BREED SPECIFIC
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 Intact?
 Food & Water?
 Frequent
Urination/Defecation?
 Coughing/Sneezing?
 Previous illness?
 Exercise intolerance?
 Treatments or medication?
 Allergies?
 Vaccines/Heartworm Test?
 CNS Depression?
 Activity level?
 Pain?
GOOD TO KNOW
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 Choice of drugs and route administered
 Minimize oral intake during fasting and change to injectable if
possible.
 Concurrent drug use be precautious.
CURRENT MEDICATION
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 Antibiotics
 Analgesics
 Cardio Drugs
 PPA
 Chemotherapy
 Organophosphates
 Phenobarbitol
 Insulin
SPECIFIC MEDICATIONS
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 A pre-anesthetic physical exam is required for every patient.
 Be consistent in the approach.
 This may be a head-to-tail or a body systems approach.
 All the systems are interesting to the anesthetist
 cardiovascular, respiratory, renal, and hepatic are most important.
 Recognizing abnormal changes of the body systems during a
physical exam will be difficult unless you are familiar with normal
physiological vital signs of individual species and breeds.
PHYSICAL EXAM
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 CRT, BP, mm color
 Auscultate & Palpate
 Dog- Femoral, tibial, dorsopedal, palmar digital, lingual, and caudal arteries
 Cat- Femoral, tibial, dorsopedal, caudal
 CV Dz should be controlled before anesthesia
 Diagnostic tools= Auscultation, CBC, Imaging, EKG
 Murmur- Classified 1-6
 3 or higher needs a workup
 REHYDRATE prior to anesthesia
CARDIOVASCULAR SYSTEM
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 GAS EXCHANGE
 O2 & CO2
 Upper and Lower Tract
 Upper: Nasal Cavity, Pharynx, Larynx,
and Trachea
 Sneezing & Snorting
 Lower: Bronchi, Bronchioles, &
Alveoli
 Tachypnea, Dyspnea, Cyanosis,
Tachycardia
 Normal Function
 Auscultation of all lung fields
 Wheezes, Crackles, & Stridor
 Mucous Membrane & Capillary Refill Time
 Pale = Hypothermia, Hypotension,
Hypoxemia, Vasoconstriction
 Brick Red = Blood Sludging, hypercarbia, or
endotoxemia
 What alters respiratory function?
 Pain, Stress, Discomfort, CNS Depression
 Almost all anesthetics are Respiratory depressants.
 PREOXYGENATE
RESPIRATORY SYSTEM
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 History
 PU/PD
 Odor of Urine/Breathe
 Diagnostics
 Renal Serum Chemistry- BUN & Creatinine
 Urine Specific Gravity
 Urinalysis and Culture
 Azotemic or Uremic Patient is more sensitive to anesthetics should be stabilized prior.
 Perfusion is essential
 Metabolism and excretion of drugs may be prolonged
 Use drugs that are excreted quickly (Propofol) as well as lower dosages
RENAL SYSTEM
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 Determines how well your patient can metabolize and excrete drugs
 Look for lethargy, hyperbillirubemia (jaundice), increased thirst, dark
colored urine
 Function affected by infection, toxicity, overdose of medication, PSS,
hereditary, and cancer
 Diagnostics: Alk Phos, Plasma Proteins, ALP
 Many Anesthetics will have prolonged action
 Thiobarbituates and benzodiazapenes- caution when using
 Use drugs that are short acting and recovery not relied upon metabolism
 Propofol and inhalents
HEPATIC SYSTEM
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 Diagnostic Testing
 Sometimes require anesthesia
 CT or MRI
 Evaluate the mental status of each patient
 All anesthetics will cause some degree of CNS depression
 Some nervous system disorders may require respiratory support
 Intracranial trauma or lesions will require close monitoring of CO2, which, when
elevated, can cause intracranial pressure to increase.
 Neuromuscular blocking drugs, dissociative agents, some antibiotics, and local
anesthetic techniques may be contraindicated in certain neuropathies.
NERVOUS SYSTEM
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 Diet, behavior, and duration and consistency of vomiting ± diarrhea should be noted
 Electrolytes will be altered with any substantial losses
 Abnormalities, such as tumors and foreign bodies can be detected during abdominal
palpation
 A full CBC and chemistry profile including electrolytes should be evaluated
 Diagnostic imaging
 Pain management
 Reduction in venous return due to the distension
 Arterial blood pressure is essential
 Hypoventilation due to pressure
GASTROINTESTINAL SYSTEM
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 Common abnormalities
 Ectoparasites
 Infection or abscess
 Masses or swelling
 Petechiation or bruising (can be an indication of a clotting problem)
 Alopecia (may be endocrine dysfunction)
 Fungus
 The approach to disinfection may be altered.
INTEGUMENT SYSTEM
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 The endocrine system influences many of the body systems as a
whole, and management of a patient with an ES disorder is
multifactorial. Any metabolic disturbance should be corrected or
stabilized prior to anesthesia.
 Diseases of this system may include one or more of the following:
 Diabetes
 Insulinoma
 Cushing’s disease (hyperadrenocortism)
 Addison’s disease (hypoadrenocortism)
 Thyroid disorder
ENDOCRINE SYSTEM
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 Any animal revealing thyroid dysfunction may require additional workup including thyroid
function tests.
 Hypothyroidism is associated with a decreased metabolism and is seen commonly in dogs.
 Anesthetic drug dosages will be altered (decreased) dramatically if this condition is not stabilized in
the patient prior to anesthesia. A patient may be seen with low heart rates, low blood pressure,
and prolonged recoveries.
 An overactive thyroid (hyperthyroidism) is common in cats and they will have an increased
metabolic state.
 Risks associated with this condition are increased workload on the heart and patients may be
cachectic or underweight.
 Hypertrophic cardiomyopathy can develop if not treated.
ENDOCRINE TESTING
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BODY CONDITION SCORE
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ASA STATUS
I – Minimal Risk of Healthy Patient
II- Slight Risk with Slight to Mild Systemic Change
III- Moderate Risk with systemic change & some
clinical alterations
IV- High Risk with preexisting disease; surgical
intervention may preserve life
V- Extreme Risk where patient has little chance of
survival with or without surgery
E- Attached to an individual class if an emergency
EXAMPLES
 Castration, OHE, Ortho Rads, Dental
 Pediatric or otherwise healthy geriatric
patient, TPLO
 Blocked Cat, some cardiac disease, fracture
with pulmonary contusions, Pyometra
 Liver failure, patient in shock,
hemoabdomen, uncompensated heart
disease
 Severe shock, massive hemorrhage,
massive trauma, ruptured colon
AMERICAN SOCIETY OF ANESTHESIOLOGISTS
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BASIC MINIMUM DATA
> 6yrs of age
1. PCV/TS
2. BUN/ Creat
3. ALT/Alk Phos
4. BG/ LAC
ADVANCED DAGNOSTIC DATA
< 6yrs of age
1. CBC/Chem
2. COAG
3. BMBT
4. UA/Culture
PREANESTHETIC DIAGNOSTICS
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 K+ (Potassium)
 + Charge
 Contract Muscle, Move Fluids through the
body. Intracellular Osmolality control.
Kidneys filter and excrete K+. Hyperkalemia
retention of K+ unable to excrete.
 Na+ (Sodium)
 + Charge
 Contract Muscle, Move Fluids through body.
Maintains Osmotic Pressure. Any type of
fluid loss will cause Hypernatrimia. V+,D+,
peritonitis, fever.
 Ca+ (Calcium)
 + Charge
 Neuromuscular performance, Skeletal
growth, and blood coagulation. Hypocalemic
may have cardiac contraction deficiency.
 Mg++ (Magnesium)
 + Charge
 Muscle Contraction and intracellular activity.
 Cl- (Chloride)
 - Charge
 Blood Pressure Regulation
ELECTROLYTES
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 Phosphate (HPO4-)
 - Charge
 Impacts how the body
metabolizes and regulates acid-
base balance and calcium levels
 Bicarbonate (HCO3-)
 - Charge
 Keeps acid-base status of the
body in balance and assists in
regulation of blood pH levels.
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Radiography
 Most popular method
 Assess size and shape of
internal organs
 Fluid, air, tumor, or
misshapen organ.
(GDV,Mass,Genetic)
 Bone Formation/Fracture
Ultrasound (US)
 Disease on radiograph
 Beneficial and safe diagnostic
visualize internal organs for
size, structure, and
pathological change.
 Blood Flow (oxygenated vs
deoxygenated)
DIAGNOSTIC IMAGING
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 Electrical system controls
timing of the heartbeat by
regulating heart rate and
rhythm.
 Electrical Function but not
mechanical.
ELECTROCARDIOGRAM
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 PaO2 – Oxygen Arterial Tension
 PaCO2 – Carbon Dioxide Arterial Tension
 Respiratory Function
 Oxygenation
 Ventilation Status
 pH
 Metabolic Function
ARTERIAL BLOOD GAS
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BLOOD GAS ANALYSIS
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 SUBJECTIVE- Behavior and Pain Assessment
 OBJECTIVE- Physical Exam and Diagnostic Findings
 ASSESSMENT- ASA Status
 PLAN- Anesthetic Protocol
SOAP
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 After completing a history, physical exam, and diagnostic
testing, develop an anesthesia protocol based on the findings
specific to that patient.
 Use all information available and keep a good record of each
patient.
 Provide evidence of your plan on a pre-anesthetic workup
document.
CONCLUSION
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Figure 2.5 Preanesthetic document used at Ross University School of
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 10 yrs FS Vizsla
 Sx- Right Caudal Lung Lobectomy
 HX- Coughing for ~ 2.5 months
 V+ and D+
Right TPLO (2/16)
Left TPLO (4/16)
 Current Medications
 Omeprazole
 Diagnostics
 Radiographs- Right Caudal Lung Mass and mild
pneumothorax.
 CT Scan
 Blood Gas/PCV/TS
 COAG
 Organ Systems
 Respiratory 5 cm Mass Right Caudal Lung Lobe
 GI V+/D+
 ASA III BLS
 Premed- Cerenia, Methadone, Pantoprazole.
 Induction- Propofol, Midazolam, Lidocaine, Ketamine
 CRI- Fentanyl, Lidocaine, Ketamine
 Pressors- Dopamine PRN
 Catheters- Peripheral, Sampling, Arterial
 Fluid Rate 10ml/kg/hr then 5ml/kg/hr
 Antibiotics Cefazolin
 Blocks- Nocita
 Position Left Lateral Recumbancy
JADE PRIVITERA
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 Toxins that would normally be filtered in the liver are
allowed to circulate back through the body
 Intrahepatic - within the liver parenchyma and account for
roughly 30% of all diagnosed shunts
 Extrahepatic- occurring outside the parenchyma, occur
more commonly in smaller-breed dogs
 The liver can atrophy due to the lack of nutrients from the
pancreas and intestines. This atrophy can potentiate liver
failure and hepatic encephalopathy
 Increased bilirubin, bile acids, white blood cell count, and
clotting times as well
 Decreased blood glucose, albumin, total plasma proteins,
and packed cell volume as well
 Hepatic encephalopathy is the inability of the liver to
metabolize any nutrients and toxins
 Attenuation is done with the use of an ameroid
constrictor placed around the abnormal vessel.
 Prolonged recovery times after a previous anesthesia
experience (i.e., spay or neuter) may be an indicator
of an existing portosystemic shunt.
 Anesthesia can be uneventful until the shunt is
ligated.Portal hypertension is the concern once the
shunt is ligated
 Because the ameroid constrictor occludes the vessel
slowly, portal hypertension is less common
PORTOSYSTEMIC SHUNTS (PSS)
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 2 yrs MI Yorkie
 SX- EHPSS + Castration
 HX- Extra hepatic large splenocaval
portosystemic shunt.
 Current Medications- Lactulose,
Metronidazole, Keppra
 Diagnostics- COAG
 ASA III BLS
 Premed- Cerenia, Keppra,
Oxymorphone
 Induction- Fentanyl, Lidocaine,
Propofol.
 CRI- Fentanyl, Lidocaine.
 Pressors- Dopamine
 Catheters- Peripheral, Sampling,
Arterial.
 Antibiotics Cefazolin
 Fluid Rate 5ml/kg/hr
HOOPER PRESTON
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QUESTIONS
theckel@uvsonline.com
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