Dr. Matthews Lecture

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XQWCat
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271055
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Dr. Matthews Lecture
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2014-04-19 23:00:49
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vet tech 247
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vet tech 247
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new analgesic drugs and newer uses of drugs in surgical nursing, anesthetic management of challenging cases, emerging issues and other problems vetc 247
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  1. recuvyra
    • transdermal fentanyl, spot on like flea/tick.  
    • control of postop pain in DOGS for 4 days with 1 application
    • FDA approved.  Reversible
    • apply 2-4h before surgery, hold 2 mins to dry
    • complete safety information, training required
  2. Buprenorphine SR
    • partial mu opioid agonist, injectable
    • not FDA approved
    • 72 hour duration
    • cats only
  3. cimicoxib
    • coxib NSAID, not in US (UK and Europe)
    • chewable tab
    • SID, 2h prior to surgery, 3-7 days post-op
  4. alfaxalone/alfaxan
    • synthetic neuroactive steriod that acts on gaba receptors, like propofol (but clear)
    • already used in australia and canada, approved in US 2012 (DEA schedule IV)
    • slow IV, apnea, twitching/paddling, CRI, okay for pups <12 weeks. 
    • Good for cardio with hypovolemia, less cardiac depression (hypotension) than propofol
  5. methadone
    • opioid becoming popular
    • mu-receptor agonist and NMDA-receptor inhibitor
    • less vomiting and dysphoria than other opioids
    • no hepatic glucuronidation, good for cats
    • better painkiller than torb or bupe
  6. pregabalin
    • anticonvulsant (metabolite of gabapentin), tx of neuropathic and chronic pain in dogs and cats
    • better bioavailability, lower dose, fewer side effects
    • expensive
  7. desflurane
    • newest of inhalants
    • High vapor pressure, heated vaporizer (hard to transport)
    • low solubility (rapid uptake, rapid elimination)
    • Start high on vaporizer
    • great for horses
    • more coughing than with sevo
  8. sevoflurane vs desflurane
    • more coughing with desflurane
    • no significant difference in time to recovery or discharge
  9. lidocaine patch
    • old drug, new preparation.  Approved for humans.  Can be cut.  
    • goats and cats have lidocaine toxicity problems
    • safe in dogs
  10. Anipryl/selegiline
    • behavior modifier for senile old dogs
    • MAO inhibitor, enhanced catecholaminergic activity
    • don't use with demerol, alpha-2 agonists (cardio), Tri-cyclic antidepressants, SSRI's
  11. Clomicalm (Clomipramine HCl)
    • behavioral modification (anxiety)
    • interacts with anticholinergics, sympathomimetics, CNS-active drugs, general anesthetics
  12. tri-cyclic antidepressants
    • decrease uptake of neurotransmitters after initial INCREASE (this window is especially dangerous) for 2 weeks
    • DO NOT ANESTHETIZE FOR FIRST 2-3 WEEKS
    • long half-life, highly protein bound, require hepatic metabolism, renal excretion, affected by age and acid-base, may affect clearance of other drugs
  13. List of tricyclic antidepressants
    • amitriptyline
    • desipramine, doxepine
    • nortriptyline
    • used for behavior modification
  14. side effects of tricyclic antidepressants
    • tachycardia
    • hypotension
    • hypertension
    • serious dysrrhythmias
    • CNS effects: sedation to seizures
  15. fluoxetine (Reconcile)
    • selective serotonin reuptake inhibitor (SSRI)
    • used for separation anxiety
    • not for use with MAOI's, TCA's
    • seizures, weight loss
  16. mirtazepine (Remuron)
    • tetracyclic antidepressant
    • no veterinary label
    • sued as appetite stimulant, side effects include nausea and vomiting
    • Not used with clonidine, MAOIs, SSRIs, TCAs, Celebrex, Tagamet, Cipro, ketoconazole
    • kidney or liver disease
    • Hypo, hypertension, tachycardia
  17. Drugs that interact with anesthetics
    • phenylpropanolamine (PPA--proin, etc)
    • phenoxybenzamine
    • both produce cardiac arrhythmias
    • propantheline (tachycardia, hypertension with anesthetics)
  18. exotic breed anesthesia
    minimal drugs with maximal monitoring
  19. P-glycoprotein expression
    • multidrug resistance gene
    • P-glycoprotein limits drug entry into CNS
    • Deficient in collies and Australian shepherds (ivermectin sensitivity)
  20. greyhound anesthesia
    • racing vs retired - how fit the animal is
    • propofol best for induction, acepromazine best as premed
    • hyperthermia may be from excitement (shivering)
    • blood values are different - high hematocrit
  21. general approach to challenging patients
    • thorough physical exam
    • how/why is this patient different, physiologically, and how will that affect drugs chosen
    • what problems are likely to occur
    • how can you prevent or manage problems
  22. emergency preparedness
    • emergency drug dose sheets
    • emergency drugs and equipment in location separate from all drugs
    • check drug dating
    • run fire drills
  23. preoperative lab work
    • no firm guidelines on standard of care
    • depends on practise, client, relationship, breed/species
    • establish a baseline
  24. preoperative fasting guidelines
    • 6-8 or 8-12h food, 2-4h or no withdrawing of water.  
    • for humans calorie loaded clear fluids recommended up to 2 hours before
  25. clinical problem with F-circuits
    • rebreathing when inside tube disconnects
    • designed for single-use
  26. the trouble with cats
    • difficult to restrain
    • behavior (O may not know)
    • difficult to intubate
    • small size = rapid changes
    • monitoring equipment often fails (too small)
    • more underlying disease than we know
  27. premeds for cats
    • acepromazine
    • midazolam
    • butorphanol (can be combined with ace or midaz)
    • ketamine (low dose as sedation, high dose as anesthetic)
    • buprenorphine
  28. propofol in cats
    • no approved for cats (though it works)
    • slow IV (titrate)
    • NOT with a ketamine premed
  29. common complications in cats
    • "wound up" cat - sudden arrest from too many catecholamines
    • tracheal trauma - too light at intubation or position changes
    • bronchoconstriction at extubation (albuterol inhalation)
    • difficult to keep asleep and monitor
    • easier to intubate bronchus (short neck)
  30. ketamine
    • NMDA receptor (N-methyl-D-Asparatate) antagonist
    • prevents wind-up and sensitization
    • supports blood pressure and heart rate while maintaining anesthesia
  31. geriatrics
    • underlying renal or cardiac disease
    • have "blunted" responses to reflexes (no baroreceptor, etc)
    • less muscle, higher body water
    • adverse response to hospital environment
  32. opioid analgesics as a pre-anesthetic
    • may provide sedation
    • provide pre-emptive analgesia
    • respiratory depression
    • bradycardia
    • minimal cardiovascular depression
    • good for geriatric
    • reversible
  33. hydromorphone
    • almost identical to oxymorphone, but less expensive
    • may produce more vomiting
  34. buprenorphine vs butorphanol
    • both good for geriatrics
    • torb shorter duration
    • bup lasts longer
    • fairly inexpensive
    • no vet approval in US
  35. induction for geriatrics
    • propofol
    • etomidate - little cardiovascular depression. Good for old, sick, high-risk (rough on healthy)
    • ketamine/diazepam or telazol (maintain BP and HR)
    • mask induction (only 1 drug on board, but must get too deep to intubate)
  36. sevoflurane
    • low solubility = 0.65
    • MAC = 2.3%
    • metabolism < 5%
    • approved for dogs, often used in cats
    • good mask inductions (not smelly)
    • less bronchial spasms than iso (asthmatics?)
  37. indications for sevoflurane
    • high-risk patients - where good control is important
    • fewer arrhythmias (like iso)
    • cesarian sections (puppies get rid of it fastest)
    • outpatient procedures - early discharge
    • good for problem cases
  38. problems for maintenance for geriatrics
    • hypotension - use of IV catheter and fluids is essential
    • restore fluid balance before anesthesia
    • inhalants allow rapid depth change and recovery, produce hypotension in dose-dependant, minimize drugs requiring metabolism
  39. uses of local anesthetics
    • good to minimize inhalants
    • epidurals, local infiltration, anatomic nerve blocks, "splash blocks", dental blocks
    • lidocaine (short term), bupivicaine (long duration)
  40. lidocaine
    • local anesthetic
    • CRI will reduce MAC for inhalants 30-50%
    • not recommended for cats due to cardiovascular depression
  41. bupivicaine
    marcaine, lasts 8-12 hours but takes 20-30 mins to produce block
  42. fentanyl CRI
    • short-acting opioid
    • stop before extubation
    • will allow vaporizers to be marked down markedly
    • minimal cardivascular depression
  43. pediatric patient concerns
    • heart-rate dependant (no complementary vaso, can't fix CO)
    • immature liver and kidneys
    • less body fat, higher water concentration
    • fast metabolic rate
    • easy to intubate bronchus
    • small size
    • care with fluid administration
    • plain saline to avoid too much heparin
    • WEIGHT of drape may impede ventilation
    • difficult to monitor (too small)
  44. things to do for pediatrics
    • use anticholinergics (premed with glyco and torb, induce with propofol, ket/val, telazol, maks, maintain with inhalant)
    • not before 4-6 weeks
    • shorter acting drugs preferred
    • keep warm
    • check blood glucose
    • tendency towards lower blood pressure
    • monitor temp, glucose, BP, HR, RR, CO2
  45. pregnant/cesarian section concerns
    • elective vs sick
    • who is priority?
    • ALL DRUGS CROSS PLACENTA, a matter of concentration and time.
  46. Cross the placenta
    • ALL DRUGS CROSS PLACENTA, just an issue to time/concentration
    • anesthetic drugs cross fast, lipid-soluble for blood-brain means can go across placenta
    • glyco crosses VERY slowly
    • epidural doesn't keep them from moving
    • Can't prevent pups from getting drugs, use one they can get rid of fast like propofol/sevo or reversible
    • Maintenance of BP VITAL to ensure blood flow to uterus (preload fluids)
    • NSAIDs hard on puppy kidneys
  47. bracycephalics
    • airway nightmare
    • prevent panting/agitation: avoid mu, use ace
    • use drugs which produce rapid, smooth recovery
    • airway swells, steroids or lasix?
    • extubate late
    • prep for tracheostomy
    • monitor temp
  48. angry mean dogs
    • telazol, torb
    • get meds into dog, don't care where
    • pre-med with hydromorphone and ace
    • induct with propofol, more telazol or mask
    • No alpha-2 agonists (can't trust)
    • watch high catecholamines (collapse, arrhythmias)
  49. telazol
    • tiletamine-zolazepam
    • IM, SQ, IV
    • recovery time is dose-dependant
    • approved for IM in dogs and cats
  50. common problems to anticipate, prepare for and stay ahead of
    • hypoglycemia
    • hypotension (hypovolemia, hypoproteinemia)
    • hypothermia
    • pain
    • cardiac arrhythmias
  51. anticholinergics as a premed
    • not if high heart rate
    • handling GI will produce vagal response
  52. opioids as premed
    • beware of producing vomiting
    • IV administration just prior to induction or can give after induction
    • choice of opioid may affect vomiting
  53. induction drug protocol
    • pre-oxygenation is important
    • titrate dose
    • mask may be okay if no vomiting
    • induce while attached to monitors
  54. propofol vs etomidate
    • etomidate causes transient immune suppression
    • decision based on cardiac function
    • could also use ketamine/diazepam
  55. drugs for epidurals
    • local anesthetic: lidocaine, bupivicaine
    • opioid: morphine, oxymorphone
    • combination of both
    • intra- and post-operative analgesia
  56. intra-operative management
    • titrate inhalant needs, may be minimal as sickness decreases MAC
    • multiple catheters may be needed
    • MONITOR
    • support aggresively: fluids, inotropes, colloids
  57. blood gas analysis
    • useful for eval of acid-base (venous sample okay)
    • electrolytes
    • lingual vein is good for sampling
  58. MAC requirements decreased by
    • age
    • hypothermia
    • concurrent drug administration
    • disease
    • when it doubt, turn it down
  59. intraoperative analgesics
    • lidocaine CRI - decrease vaporizer to offset hypotension
    • fentanyl CRI
    • ketamine CRI
    • opioids by bolus
  60. emergency preparedness
    • emergency drugs available
    • dosing chart available
    • drug sheet preprinted per patient
  61. inotropic drugs
    • dobutamine
    • dopamine
    • ephedrine
    • vasopressin
    • epi/norepinephrine
  62. colloids
    • hetastarch
    • newer colloids (pentastarch)
    • hypertonic saline
    • combination of hetastarch and hypertonic saline
  63. hypothermia
    • decreases need for inhalants
    • prolongs recovery
    • slows heartrate
    • can cause cardiac collapse
    • open abdomen can cause
  64. renal disease considerations
    • maintain blood pressure (MAP > 65-70 mmHg)
    • IV fluids recommended
  65. cardiac disease considerations
    • cardiac-sparing drugs (like opioids)
    • caution with fluid administration
  66. the key to success with difficult cases
    • monitoring
    • HR, respiratory rate, depth of respiration, BP, SpO2, capnography, ECG, blood gas

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