Surgery and Anesthesia management
Krittee Dejyong D.V.M.,M.Sc.
Surgical appointment
The Anesthesia management
• Anesthesia preparation
Health checkup
• Physical examination
• HR, RR, Temp
• Blood glucose
Premedication
• Antibiotic
• Analgesia
• Sedatives?
Circulation
• IV placement
• Fluids
Respiration
• Endotracheal tube
• Oxygenation
• Ventilation
Monitoring
HR, EKG, RR, O2sat, BP,
EtCO2, Temp
Anesthesia Stages
Aseptic process
Hair clip
Cleaning
Antiseptic
American Society of Anesthesiologists (ASA)
Emergency drug calculationDrugs Dosages Routes Conditions Contraindications
Adrenaline 0.02-0.2mg/kg IT,IV Cardiac resuscitation Hypertension, arrhythmias
Atropine 0.022-0.044mg/kg IM,SC,IV Bradycardias, AV blocker, Cholinergic toxicity Constipation, vomiting, thirst, depression pupil dilatation and photophobia
Calcium Gluconate 0.5-1.5ml/kg
0.5-1ml/kg over 10-20 min
Slow IV Hypocalcemia
Hyperkalemia
Ventricular fibrillation patients,/hypotension cardiac arrhythmia cardiac arrest
Chlorpheniramine Dog:0.5mg/kg
Cat: 2-4mg/cat
IM Antihistamine Depression,lethargy,
Dexmethasone Dog:4-6mg/kg
Cat:5mg/kg
IV
IV
Endoxtoxic, Septic shock PU/PD, pancreatitis, GI-ulceration, lipidemias (long term therapy)
Diazepam Dogs:0.1 mg/kg
0.2-0.6mg/kg
0.5-2mg/kg Cat:0.5-1mg/kg
Slow IV
IV
IV, Rectum
Preansthesia
Sedation
Seizures
Weakness, ataxia ,CNS depressant
Diltiazem 0.125-0.35mg/kg
0.5mg/kg q6h
IV
PO
Acute Supraventricular tachycardia
Emergency hypertension
Bradycardia or 2nd or 3rd degree AV block
Dobutamine Dog:2.5-1mcg/kg/min
Cat:4.4-15.4mcg/kg/min
IV CRI Short-term treatment of Low dardiac output and acute heart failure Ectopic beat,Tachycardia,fatigue
Dopamine 0.5-3mcg/kg/min
1-5mcg/kg/min
IV CRI Diuretic
Severe hypotension, Shock
Vomiting,Tachycardia,ectopic beats
Furosemide 2-4mg./kg q6-8h
Dog:2-8mg/kg q1-2h Cat :1-4 mg/kg
IV,IM,PO
IV,IM
Diuretic
Severe pulmonary edema
Hypotension, hypokalemia, hypomagnesemia, hypocalcemia
Flumazenil 0.01mg/kg IV Antagonist for Benzodiazepines Increased muscle tone, hyperesthesia, convulsions
Glycopyrrolate 0.1 mg/kg IV,IM,SC Bradyarrhythmias Tachycardia
Heparin Dog:500 Unit/kg q8h
Cat:250-375U/kg q8h
SC Thromboembolism
DIC Please find more information
Bleeding and thrombocytopenia
Insulin (Regular) 0.1-0.2 U/kg q1h
0.05-0.1U/kg/h CRI
0.25-0.5U/kg + 50% dextrose
IM
IV CRI
Slow IV
DKA
DKA
Severe hyperkalemia
Hypoglycemia
Lidocaine Dog:1-2mg/kg bolus over 30 min IV Life threatening ventricular tachycardia Ataxia, depression, seizures, bradycardia, hypotension
Mannitol 0.5-1.5g/kg over15-20min
0.5-1g/kg over15-20min
IV
IV
Diuretic, Cerebral edema
Glaucoma
Fluid and electrolyte imbalance
Naloxone 0.015 to 0.04 mg/kg
Dog: 2 mg/kg/hour
Cat: 8 mg/kg/hour
IV,IM,SC
IV CRI
IV CRI
Opioids reversal
Reverse endorphin-mediated hypotension (septic shock)
Preexisting cardiac abnormalities
Propranolol 0.02mg/kg Slow IV Cardiac arrhythmias, Beta-Blocker, Hypertension Hypotension, bradycardia, bronchospasm, hypoglycemia, hyperkalemia, pul
monary edema
Verapamil Dog:0.05-0.25mg/kg
Cat: 0.025mg/kg repeat every 5 min
IV
IV
Supraventricular tachycardia Cardiogenic shock and severe congestive heart failure, HCM Hepatic-renal i
mpairment ,Hypotension
Yohimbine 0.1mg/kg IV Xylazine reversal Cautiously with seizure and hypertensive patients
Emergency drug calculation
DWV/R(16.67)
Circulation
• IV catheterization– Aseptic– Location– Restraint?
• Fluid– Type– Rate– Volume
IV catheter
Type of FluidFluid mEq/L pH mOsm/L
Na Cl K Ca Mg Glucose(g/L) Buffer Kcal/L
Plasma 142 103 4 5 2 - Bicarb 22-32 - 7.4 289
Interstitial 140 117 4.5 5 2 - Bicarb 28 -
Intracellular 10 103 150 1 40 - Bicarb 7 -
0.45%NaCl 77 77 - - - - - 0 5.7 154
0.9%NaCl 154 154 - - - - - 0 5.7 308
7.5%NaCl 1283 1283 - - - - - 0 5.7 2567
LRS 130 109 4 2.7 - Lactate 28 9 6.5 273-280
ARS 130 110 4 2 1 - Acetate 30 270-290
D5W - - - - - 50 - 170 5.0 252
D5S 154 154 - - - 50 - 170 4.4 560
D51/2S 77 77 - - - 50 - 170 4.4 405
Fluid rate
• Normal hydration
– 5-10ml/kg/hr
– Calculate limit for 1hr
Respiration
• Endotracheal intubation
Respiration
• Anesthesia machine
Anesthesia machine
Anesthesia machine
Monitoring
• Anesthesia Stages– Stage I (stage of analgesia or disorientation):
• Induction of general anesthesia loss of consciousness.
– Stage II (stage of excitement or delirium): • Loss of consciousness automatic breathing
• Eyelash reflex disappear but other reflexes remain intact and coughing, vomiting and struggling may occur; respiration can be irregular with breath-holding.
Anesthesia Stages• Stage III (stage of surgical anesthesia)
– onset of automatic respiration respiratory paralysis.
– Plane I • Automatic respiration cessation of eyeball movements. • Eyelid reflex is lost, swallowing reflex disappears, marked eyeball movement may occur but conj
unctival reflex is lost at the bottom of the plane
– Plane II • Cessation of eyeball movements beginning of paralysis of intercostal muscles. • Laryngeal reflex is lost although inflammation of the upper respiratory tract increases reflex irrit
ability, corneal reflex disappears, secretion of tears increases (a useful sign of light anesthesia), respiration is automatic and regular, movement and deep breathing as a response to skin stimulation disappears.
– Plane III • Completion of intercostal muscle paralysis. • Diaphragmatic respiration persists but there is progressive intercostal paralysis, pupils dilated an
d light reflex is abolished. • The laryngeal reflex lost in plane II can still be initiated by painful stimuli arising from the dilatat
ion of anus or cervix.
– Plane IV • Complete intercostal paralysis diaphragmatic paralysis (apnea).
Anesthesia Stages
• Stage IV: – Stoppage of respiration death. – medullary paralysis with respiratory arrest and v
asomotor collapse. – Pupils are widely dilated and muscles are relaxe
d.
Eye ball position
Vital signs monitoring
Heart rate HR Stethoscope
EKG monitor
-
Pulse rate PR Pulse oxymeter -
Elctrocardiogram ECG EKG monitor -
Respiratory rate RR Capnometer -
Blood pressure BP OscillometryDoppler ultrasonic
Systolic BP >120
Blood-Oxygen
saturation
O2sat Pulse oxymeter 95-100 (100%O2)
Endtidal Carbondioxide ETCO2 Capnometer 35-45
Temperature Temp Thermometer 100-103 F(37.8-39.4 C)
Electrocardiography(ECG)
Electrocardiography(ECG)
Electrocardiography(ECG)
Electrocardiography(ECG)
Electrocardiography(ECG)
Blood pressure measure
• Non invasive (IBP) VS NIBP
• NIBP Cuffing– 40%-50% of limb circumference
– Too tight occlude venous return false low BP
– Dogs or cats less than 5 lbs brachial artery
– Cuff should be maintained as close to the level of the right atrium as possible.
Anesthesia record
At least every 5 min!
HRPRRRBP O2sat ETCO2
TempAnesthesia stage
%anesthesia gasO2FlowFluid
Patient data
Anesthetic drug
Aseptic technique
• Clean– Reduce overall microorganisms
• Asepsis– Free from pathogenic microorganisms and reduce
microorganisms to minimum
• Sterile• Free from all microorganisms
Aseptic technique• Joseph Lister: father of modern surgery
– 1864-66 death rate 45.7%– 1867-70 death rate 15%
1. UN-STERILE PERSONS AVOID STERILE AREAS2. STERILE PERSONS AVOID LEANING OVER AN UN-STERILE AREA. UN-STERILE PERSONS AVOI
D LEANING OVER STERILE FIELD.3. PERSONS WHO ARE STERILE TOUCH ONLY STERILE ITEMS/AREAS. UNSTERILE PERSONS TOUCH
ONLY NON-STERILE ITEMS ARE SPACES.4. STERILE AREAS ARE CONTINUOUSLY KEPT IN VIEW.5. ONLY STERILE ITEMS ARE USED WITHIN A STERILE FIELD.6. MICROORGANISMS MUST BE KEPT TO AN IRREDUCIBLE MINIMUM7. DESTRUCTION OF THE INTEGRITY OF MICROBIAL BARRIERS RESULTS IN CONTAMINATION.8. GOWNS ARE CONSIDERED STERILE FROM TABLE LEVEL TO CHEST LEVEL IN FRONT INCLUDING
SLEEVES TO 2 IN ABOVE THE ELBOWS9. AS STRERILE PACKAGES ARE OPENED, THE EDGES OF THE WRAPPER ARE CONSIDERED UNS
TERILE10. STERILE PERSONS KEEP WITHIN STERILE AREAS.11. DRAPED TABLES ARE STERILE ONLY AT TABLE LEVEL12. A STERILE FIELD IS CREATED AS CLOSE TO THE TIME OF USE AS POSSIBLE.
Surgical instrument
Operative Zone
Operative Zone
Antiseptic and disinfectant
• Antiseptics– Biocides or products that destroy or inhibit the growth of
microorganisms in or on living tissue
• Disinfectants– Similar but generally are products or biocides that are used
on inanimate objects or surfaces
Antiseptic and disinfectant• Glutaraldehyde
– Bacteria, viruses, fungi and sporicidal
– endoscopes and surgical equipment
• Peroxygens (Hydrogen peroxide (H2O2))
– Bacteria, viruses, yeasts
– Hydroxyl free radicals (•OH) which attack essential cell components, including lipids, proteins, and DNA
• Alcohols
– Bacteria, viruses, and fungi but are not sporicidal
• Biguanides (Chlorhexidine )
– Bacteria, viruses and sporostatic
– pH dependent and is greatly reduced in the presence of organic matter
• Halogen-Releasing Agents (Chlorine)– Bacteria, viruses, fungi and sporicidal
• Iodine and iodophors
– Bacteria, viruses, fungi and sporicidal
Sterilization
• Eliminates (removes) or kills (deactivates) all forms of life excluding all prions
• Heat– Steam
• Autoclaves 20 mins at 121 °C at 100 kPa• Prion elimination (BSE) 121-132 °C for 60 mins or 134 °C for at least 18 mins• Indicators
– Indicator tape– Geobacillus stearothermophilus (optimum 60 and 65 °C)
– Dry Heat• Hot air oven is at least two hours at 160 °C• 190 °C for 6 minutes for unwrapped objects and 12 minutes for wrapped objects
– Flaming• Bunsen burner or alcohol lamp
– Incineration• Burns any organism to ash
– Tyndallization• Boiling for a period (typically 20 minutes) at atmospheric press
ure cooling, incubating for a day, then repeating the process a total of 3 to 4 times
• Spores are stimulated to grow by the heat shock
– Glass bead sterilizers• Heating glass beads to 250 °C
Sterilization
Sterilization
• Chemical sterilization– Ethylene oxide
• Medical device
– Nitrogen dioxide• Common bacteria, viruses, and spores
– Ozone• Water and air
– Glutaraldehyde and formaldehyde• Kill all spores in 22 hrs
– Hydrogen peroxide• Conc. 35% up to 90%----28 minutes
– Peracetic acid (0.2%)• Medical devices such as endoscopes.
Sterilization
• Radiation sterilization– Ultraviolet light
• Ineffective in shaded areas, including areas under dirt
• It also damages some plastics, such as polystyrene foam
– Gamma radiation• syringes, needles, cannulas and IV sets
• Cobalt-60(60Co) or caesium-137 (137Cs)
– High-energy X-rays• large packages and pallet loads of medical devices
Discharge form
Post operative care
Operation room
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