Transcript
Buenos aires 2007 tiva
Prof. Yves MoensPhD, PD, Dipl. ECVAProf. Yves Moens
PhD, PD, Dipl. ECVA
Anesthesia with total intravenous anaesthesia: an
option?
Anesthesia with total intravenous anaesthesia: an
option?
VeterinaryUniversity
Buenos aires 2007 tiva
Inhalation anesthesia
Parenteral anaesthesia-Intramusular (short-repeated)-Total intravenous anesthesia (TIVA)
• Repeated boli• Continuous rate infusion
Inhalation anesthesia
Parenteral anaesthesia-Intramusular (short-repeated)-Total intravenous anesthesia (TIVA)
• Repeated boli• Continuous rate infusion
Buenos aires 2007 tiva
General anaesthesia riskGeneral anaesthesia risk
Horses: 1%Human: 0,001%Small animals: 0,1%
Horses: 1%Human: 0,001%Small animals: 0,1%
Buenos aires 2007 tiva
Anaesthetic-related mortality risks in small animals in the UK
Anaesthetic-related mortality risks in small animals in the UK
1,40%1,33%SICK0,112%0,054%HEALTH
Y
CATDOG
Brodbelt D. et al. AVA spring meeting, Rimini, Italy 20-23 april 2005, 29, 417-23
Buenos aires 2007 tiva
Anaesthesia requirements: every veterinarian who will perform a general anaesthesia must be able to
Anaesthesia requirements: every veterinarian who will perform a general anaesthesia must be able to
Ensure the airway permeabilityAdminister oxygenPerform IPPVAdminister IV drugsPerform CardioPulmonary Resuscitation
Ensure the airway permeabilityAdminister oxygenPerform IPPVAdminister IV drugsPerform CardioPulmonary Resuscitation
Buenos aires 2007 tiva
IMPORTANCE OF OXYGENIMPORTANCE OF OXYGEN
HYPOVENTILATION
HYPERCAPNIAHYPOXEMIA
INSUFFICANCY OF O2 IN THE CENTRAL NERVOUS SYSTEM
RESPIRATORY ARREST
CARDIAC ARREST
ANAESTHESIAWITHOUT OXYGEN
Buenos aires 2007 tiva
IMPORTANCE OF OXYGENIMPORTANCE OF OXYGEN
HYPOVENTILATION
HYPERCAPNIANORMOXEMIA
ANAESTHESIAWITH OXYGEN
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Administer oxygenAdminister oxygen
O2 thankConcentratorO2 thankConcentrator
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Breathing system
patient
Bain system
Fresh gaz flow
100 mL/Kg/minwith minimum 1L
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2
Circle system
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Administer IV drugsAdminister IV drugs
IV catheterIV catheter
Buenos aires 2007 tiva
Perform CardioPulmonary Resuscitation
Perform CardioPulmonary Resuscitation
A AIRWAYB BREATHINGC CIRCULATIOND DRUGSE ECGF FLUIDS
A AIRWAYB BREATHINGC CIRCULATIOND DRUGSE ECGF FLUIDS
Buenos aires 2007 tiva
Perianaesthetic considerationsPerianaesthetic considerations
Hypothermia preventionHypovolemia preventionProtection of the cornea
Hypothermia preventionHypovolemia preventionProtection of the cornea
Buenos aires 2007 tiva
Good TIVA (parenteral) is.....Good TIVA (parenteral) is.....
ensure the airway permeability (intubation)Administer oxygen (also very simple)able to perform IPPV also simple if necessary
able to perform CardioPulmonary resuscitation if necessary
ensure the airway permeability (intubation)Administer oxygen (also very simple)able to perform IPPV also simple if necessary
able to perform CardioPulmonary resuscitation if necessary
Buenos aires 2007 tiva
General Anaesthesia?General Anaesthesia?
State, resulting from the unconsciousness induced by drug(s) where the patient neither perceives nor remembers noxious stimuli
State, resulting from the unconsciousness induced by drug(s) where the patient neither perceives nor remembers noxious stimuli
Prys Roberts, 1987
Buenos aires 2007 tivaNoxious stimuli
autonomoussomatic
sensitive
respiratory
motorhaemo-dynamic
Prys-Roberts, 1987
hormonal
Buenos aires 2007 tivaNoxious stimuli
autonomoussomatic
sensitive
respiratory
motorhaemo-dynamic
Prys-Roberts, 1987
hormonal
Buenos aires 2007 tivaNoxious stimuli
autonomoussomatic
sensitive
respiratory
motorhaemo-dynamic
Prys-Roberts, 1987
hormonal
Buenos aires 2007 tivaNoxious stimuli
autonomoussomatic
sensitive
respiratory
motorhaemo-dynamic
Prys-Roberts, 1987
hormonal
Buenos aires 2007 tiva
surgery=
pain/nociception
Buenos aires 2007 tiva
pain/nociception
stress situation
Buenos aires 2007 tiva
pain/nociception & stress
morbidity
mortality
Buenos aires 2007 tiva
Goals of general anaesthesia for surgical procedure
Goals of general anaesthesia for surgical procedure
unconsciousness
analgesia myorelaxation
Buenos aires 2007 tiva
QuickTime™ and aPhoto - JPEG decompressor
are needed to see this picture.how to choose the most adapted
strategy?
Buenos aires 2007 tiva
7 foundations to construct your anaesthesia strategy
7 foundations to construct your anaesthesia strategy
1. Patient condition2. Aim of anaesthesia3. Nature of surgery4. Environment5. Equipment6. Knowledge7. Staff avalaibility & qualification
1. Patient condition2. Aim of anaesthesia3. Nature of surgery4. Environment5. Equipment6. Knowledge7. Staff avalaibility & qualification
Buenos aires 2007 tiva
Preanesthetic examinationPreanesthetic examination
Clinical examinationLaboratory analysisSpecialized examination
Food fasting: 12 HWater fasting: 2 H
Clinical examinationLaboratory analysisSpecialized examination
Food fasting: 12 HWater fasting: 2 H
Buenos aires 2007 tiva
ASA classificationASA classification
emergencyE
very highV
highIV
moderateIII
lightII
minimalI
Buenos aires 2007 tiva
Aim of anaesthesiaAim of anaesthesia
Surgical procedureor
No nociception expected
Surgical procedureor
No nociception expected
Buenos aires 2007 tiva
Nature of surgeryNature of surgery
Expected durationDegree of nociceptionLocation of the surgeryAmbulatory anaesthesia (‘one dayclinic’)
Expected durationDegree of nociceptionLocation of the surgeryAmbulatory anaesthesia (‘one dayclinic’)
Buenos aires 2007 tiva
EnvironmentEnvironment
Quiet?Quiet?
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Anaesthesia equipmentAnaesthesia equipment
Gas (O2, N2O, AIR) delivery systemInhalational agent(s) delivery systemBreathing systemVentilatory supportIntravenous agent(s) delivery systemMonitoring
Gas (O2, N2O, AIR) delivery systemInhalational agent(s) delivery systemBreathing systemVentilatory supportIntravenous agent(s) delivery systemMonitoring
Buenos aires 2007 tiva
Anaesthetic protocol
unconsciousness
analgesia myorelaxation
Buenos aires 2007 tiva
Place of analgesia during anaesthesiaPlace of analgesia during anaesthesia
Preemptive analgesia before surgeryNociception control during maintenance of anaesthesiaBalanced anaesthesia with systemic analgesic(s) and/or locoregional technique
Preemptive analgesia before surgeryNociception control during maintenance of anaesthesiaBalanced anaesthesia with systemic analgesic(s) and/or locoregional technique
Buenos aires 2007 tiva
Preemptive analgesiaPreemptive analgesia
injury
hypersensitivityfrom Woolf & Chang Anesth Analg 1993 77: 362-79
Buenos aires 2007 tiva
Preemptive analgesiaPreemptive analgesia
injury
hypersensitivityfrom Woolf & Chang Anesth Analg 1993 77: 362-79
a
Buenos aires 2007 tiva
Preemptive analgesiaPreemptive analgesia
injury
hypersensitivityfrom Woolf & Chang Anesth Analg 1993 77: 362-79
pa
Buenos aires 2007 tiva
Balanced anaesthesiaBalanced anaesthesia
Differents drugs and/or techniques in ordre to achieve the goals of general anaesthesia.
Differents drugs and/or techniques in ordre to achieve the goals of general anaesthesia.
unconsciousness
analgesia myorelaxation
Buenos aires 2007 tiva
yesLocal anesthyesN2O
yesyesHalogenated yesyesPropofol
yesdependsDissociative yesyesBarbiturates
yesOpioids yesyesAlpha2agon yesBenzodiaz yesPhenothiaz
Myorelaxa-tion
Uncons-ciousness
Analgesia DRUGSproperties
Buenos aires 2007 tiva
ASA classificationASA classification
emergencyE
very highV
highIV
moderateIII
lightII
minimalI
Buenos aires 2007 tiva
Analgetic strategy during anaesthesiaAnalgetic strategy during anaesthesia
SYSTEMIC OPIOIDS
SYSTEMIC
α 2 AGONISTS
LOCAL ANESTHESICS
KETAMINE
BALANCED ANALGESIA
main
complementoryN2O
Buenos aires 2007 tiva
Balanced anaesthesiaBalanced anaesthesia
Stress-free anaesthesia
Reduction of the dosage and side effects of « general anaesthetics »
Contribution to beter postoperative pain control
Stress-free anaesthesia
Reduction of the dosage and side effects of « general anaesthetics »
Contribution to beter postoperative pain control
Buenos aires 2007 tiva
Drugs for tivaDrugs for tiva
short half life timenot accumulating short half life timenot accumulating
Buenos aires 2007 tiva
Context Sensitive Half LifeContext Sensitive Half Life
From http://dailymed.nlm.nih.gov
Buenos aires 2007 tiva
Context Sensitive Half LifeContext Sensitive Half Life
From Shafer, Anesthesiology 1991; 74:53
Buenos aires 2007 tiva
Context Sensitive Half LifeContext Sensitive Half Life
From Schafer, J Clin Anesth;, 1993
Buenos aires 2007 tiva
propofolpropofol
From Schafer, J Clin Anesth;, 1993
a very good basis for TIVA (dog)NOT analgesic! Combine with-analgesics like opiates- local anaesthesia-ketamine
a very good basis for TIVA (dog)NOT analgesic! Combine with-analgesics like opiates- local anaesthesia-ketamine
Buenos aires 2007 tiva
Intermittent boli techniqueIntermittent boli technique
Buenos aires 2007 tiva
Constant rate infusions (cri)Constant rate infusions (cri)
Buenos aires 2007 tiva
Prof. Yves MoensPhD, PD, Dipl. ECVAProf. Yves Moens
PhD, PD, Dipl. ECVA
Syringe pumps for veterinany anaesthesia: toy or tool?
Syringe pumps for veterinany anaesthesia: toy or tool?
VeterinaryUniversity
Buenos aires 2007 tiva
Where are the syringe pumps?Where are the syringe pumps?
Buenos aires 2007 tiva
Modern syringe pumps:evolutionModern syringe pumps:evolution
spring loadedsimple pumpswith information on a display
with programmable infusion sheme for delivery of anaestheticmultiple syringe sets with integrated
software for programming anesthetic delivery in time, graphic display, datadownload
drug-specific pumps for TCI withprograms for different drugs (propofol)
spring loadedsimple pumpswith information on a display
with programmable infusion sheme for delivery of anaestheticmultiple syringe sets with integrated
software for programming anesthetic delivery in time, graphic display, datadownload
drug-specific pumps for TCI withprograms for different drugs (propofol)
Buenos aires 2007 tiva
which syringes accepted?functioning on battery?specific bolus function?purge function?obstruction function (high pressure)almost empty function?
which syringes accepted?functioning on battery?specific bolus function?purge function?obstruction function (high pressure)almost empty function?
Buenos aires 2007 tiva
display possibilities? pro hr/pro min- mg/ µg/ml/
introduction concentration drug and desiredinfusion rate in ml-mg-µg/kg/hr/min etc… and weight of patient
total drug infused display? max drug to be infused function display?
new: other advanced functions like preprogramming an entire infusion shema
display possibilities? pro hr/pro min- mg/ µg/ml/
introduction concentration drug and desiredinfusion rate in ml-mg-µg/kg/hr/min etc… and weight of patient
total drug infused display? max drug to be infused function display?
new: other advanced functions like preprogramming an entire infusion shema
Buenos aires 2007 tiva
Target Controlled Infusion (TCI)Target Controlled Infusion (TCI)
common TIVA technique in human for propofol; Syringue “DIPRIFUSOR”
anaesthesist chooses the target plasma level he wants to obtain light to deep anaesthesia (literature)
the microprocessor knows to achieve this based on experimental data and controls the delivery rate of the pump automatically
common TIVA technique in human for propofol; Syringue “DIPRIFUSOR”
anaesthesist chooses the target plasma level he wants to obtain light to deep anaesthesia (literature)
the microprocessor knows to achieve this based on experimental data and controls the delivery rate of the pump automatically
Buenos aires 2007 tiva
Buenos aires 2007 tiva
Target Controlled Infusion (TCI)Target Controlled Infusion (TCI)
Buenos aires 2007 tiva
future: Closed-loop anaesthesiafuture: Closed-loop anaesthesia
? BIS-monitor
(bispectral edge-eeg baseg)
Buenos aires 2007 tiva
Increased use of syringe pumps to provideconstant rate infusions (cri)
Increased use of syringe pumps to provideconstant rate infusions (cri)
TIVA anaesthesia (propofol)- Simple TIVA- TCI- TIVA: target controlled infusion
Peroperative- analgesic support: different drugs and mixtures- inotropic support (dopamine, dobutamine,...)- fluids, blood to very small patients
Postoperative- intravenous analgesic support- spinal analgesic support- Inotropes- other drugs (antibiotics, chemo, antiarrhythmics,...)- fluids
TIVA anaesthesia (propofol)- Simple TIVA- TCI- TIVA: target controlled infusion
Peroperative- analgesic support: different drugs and mixtures- inotropic support (dopamine, dobutamine,...)- fluids, blood to very small patients
Postoperative- intravenous analgesic support- spinal analgesic support- Inotropes- other drugs (antibiotics, chemo, antiarrhythmics,...)- fluids
Buenos aires 2007 tiva
CRI KetamineCRI Ketamine
NMDA receptor antagonistprevents central sensitation, hyperalgesie, allodynia
initial bolus: 0.25 -0.50 mg/kg0.12 -1.2 mg/kg/hr
NMDA receptor antagonistprevents central sensitation, hyperalgesie, allodynia
initial bolus: 0.25 -0.50 mg/kg0.12 -1.2 mg/kg/hr
Buenos aires 2007 tiva
CRI MorphineCRI Morphine
Potent analgesia in balanced protocolsreduces MAC of anaesthetic agents
initial bolus: 0.5mg/kg im0.12-0.36 mg/kg/hr In cats: low end of dosing spectrum
Potent analgesia in balanced protocolsreduces MAC of anaesthetic agents
initial bolus: 0.5mg/kg im0.12-0.36 mg/kg/hr In cats: low end of dosing spectrum
Buenos aires 2007 tiva
CRI FentanylCRI Fentanyl
Analgesia (200 X morphine) in balanced protocolsreduces MAC of anaesthetic agents
initial bolus: 1-5 µg/kg/hr infusion 2-20 µg/kg/hr
Analgesia (200 X morphine) in balanced protocolsreduces MAC of anaesthetic agents
initial bolus: 1-5 µg/kg/hr infusion 2-20 µg/kg/hr
Buenos aires 2007 tiva
CRI LidocaineCRI Lidocaine
reduces MAC- analgesisc properties
initial bolus: 1mg/kg over 10 minutes bolus0.6 - 3 mg/kg/hr
reduces MAC- analgesisc properties
initial bolus: 1mg/kg over 10 minutes bolus0.6 - 3 mg/kg/hr
Buenos aires 2007 tiva
CRI mixtures as TIVACRI mixtures as TIVA
Ketamine: 60 mg/500ml +Morphine: 60 mg/500ml +(Lidocaine: 500mg/500ml)
CRI: 1ml/kg/hr
Fluid rates can be increased up to 3ml/kg/hr
Ketamine: 60 mg/500ml +Morphine: 60 mg/500ml +(Lidocaine: 500mg/500ml)
CRI: 1ml/kg/hr
Fluid rates can be increased up to 3ml/kg/hr
“MILK”
Buenos aires 2007 tiva
TIVA with Ketamine and PropofolTIVA with Ketamine and Propofol
Propofol Induction Dose 0.5 mg/KgKetamine Induction Dose 1 mg/KgPropofol CRI 0.075 mg/Kg/minKetamine CRI 2 mg/Kg/hr
Propofol Induction Dose 0.5 mg/KgKetamine Induction Dose 1 mg/KgPropofol CRI 0.075 mg/Kg/minKetamine CRI 2 mg/Kg/hr
Buenos aires 2007 tiva
TIVA with Ketamine and PropofolTIVA with Ketamine and Propofol
Higher HR and Blood Pressure
Progressive Hypercapnia and Respiratory Acidosis
Faster recovery but with some Ketamine side effects
Higher HR and Blood Pressure
Progressive Hypercapnia and Respiratory Acidosis
Faster recovery but with some Ketamine side effects
Buenos aires 2007 tiva
TIVATIVA
Propofol + Fentanyl-8-16mg/kg/hr + 2-20 µg/kg/hr
Propofol + Fentanyl-8-16mg/kg/hr + 2-20 µg/kg/hr
Buenos aires 2007 tiva
TIVA with Propofol and FentanylTIVA with Propofol and Fentanyl
Propofol CRI 0.2-0.4 mg/Kg/minFentanyl Loading Dose 2 mcg/KgFentanyl CRI 0.1-0.5 mcg/Kg/minOften leading to bradycardia: AtropineLeading to apneaSpontaneous ventilation ca.25 mins after stopping Fentanyl CRIOften giving excitation during recovery
Propofol CRI 0.2-0.4 mg/Kg/minFentanyl Loading Dose 2 mcg/KgFentanyl CRI 0.1-0.5 mcg/Kg/minOften leading to bradycardia: AtropineLeading to apneaSpontaneous ventilation ca.25 mins after stopping Fentanyl CRIOften giving excitation during recovery
Buenos aires 2007 tiva
TIVA with Propofol and RemifentanilTIVA with Propofol and Remifentanil
Propofol CRI 0.33 mg/Kg/minRemifentanil CRI 0.6 mcg/Kg/minOften leading to bradycardia: AtropineLeading to apneaSpontaneous ventilation ca.10 mins after stopping Remifentanil CRISeldom giving excitation during recoveryPost-Op. analgesia to be carefully planned in time!
Propofol CRI 0.33 mg/Kg/minRemifentanil CRI 0.6 mcg/Kg/minOften leading to bradycardia: AtropineLeading to apneaSpontaneous ventilation ca.10 mins after stopping Remifentanil CRISeldom giving excitation during recoveryPost-Op. analgesia to be carefully planned in time!
Buenos aires 2007 tiva
TIVATIVA
not with thiopentalnot with only ketaminepremedication with rompun will
diminish the dosesideal is a combination with local
anaesthesia if possible
not with thiopentalnot with only ketaminepremedication with rompun will
diminish the dosesideal is a combination with local
anaesthesia if possible
Buenos aires 2007 tiva
TIVATIVA
with propofol and remifentanylquick and excellent recoveries also after long procedures
be prepared to support ventilation if necessary
supplemention with oxygen necessary
with propofol and remifentanylquick and excellent recoveries also after long procedures
be prepared to support ventilation if necessary
supplemention with oxygen necessary
Buenos aires 2007 tiva
Parenteral (TIVA) or inhalational Parenteral (TIVA) or inhalational
which is simplier or safer
respect of the general fundamental requirements for good anaesthesiapractice will improve a lot quality and safety of even the simpliestanaesthesia techniques
which is simplier or safer
respect of the general fundamental requirements for good anaesthesiapractice will improve a lot quality and safety of even the simpliestanaesthesia techniques
Buenos aires 2007 tiva
TIVA with Ketamine and PropofolTIVA with Ketamine and Propofol
Higher HR and Blood PressureLower Minute Volume and TemperatureProgressive Hypercapnia and Respiratory AcidosisFaster recovery but with some Ketamine side effectsAnalgesic properties of Ketamine
Higher HR and Blood PressureLower Minute Volume and TemperatureProgressive Hypercapnia and Respiratory AcidosisFaster recovery but with some Ketamine side effectsAnalgesic properties of Ketamine
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