Anesthesia protocols

MAJ Maren Mason, VC

DVM, MPH, DACVPM

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Disclosures

• Views are my own

• I am not an
anesthesiologist

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Outline

• Review US Army VS
anesthesia guidance

• Hear some tidbits from MAJ

M

• Discuss local anesthesia

plans and challenges?

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Remember

“There is no safe anesthetic agent; there

are no safe anesthetic procedures; there
are only safe anesthetists.”
-Robert Smith

The Veterinary Oath

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Approach to anesthetic plan

• Minimum database, PE w/ CV emphasis

• Assign an ASA score
• Select appropriate drug protocol
• Prepare for anesthetic emergencies
• Implement protocol
• Monitor protocol

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ASA Status Scale

• American Society of Anesthesiologists (ASA) Physical Status

Scale
• ASA I
• Minimal risk
• Normal, healthy, no underlying disease
• ASA II
• Slight risk
• Minor disease present, able to compensate
• Neonates or geriatrics, obese patients
• ASA III
• Moderate risk
• Moderate systemic illness, mild clinical signs
• Anemia, moderate dehydration, fever, mild cardiac disease, etc.
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ASA Status Scale

• American Society of Anesthesiologists (ASA) Physical Status

Scale
• ASA IV
• High risk
• Significantly compromised by systemic disease
• Severe dehydration, toxemia, uncompensated heart disease or
diabetes, etc.
• ASA V
• Extreme risk
• Advanced disease
• Profound shock, severe trauma; advanced heart liver kidney or
endocrine disease, etc.

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Plan

• Sedation for restraint?

• Painful surgery?
• Complete oral assessment?

• Is the crash cart stocked and

accessible?

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Plan – the anesthetic triad

Analgesia

Sedation
Muscle
Amnesia
Relaxation
Hypnosis
Narcosis

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Plan

• Mild sedation

• Deep sedation
• Healthy or unhealthy
• IV or IM

• Fractious restraint
• Healthy or unhealthy

• General Anesthesia
• Healthy or unhealthy

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Plan Categories & Goals

• Premedication   calm, easy handling, prevent

bradycardia, provide analgesia

• Induction   smooth, fast, relaxed patient

• Maintenance   easy, adjustable, good oxygenation

• Recovery   pain control, smooth, fast

All with the most minimal cardiopulmonary effects possible

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Pre-medications

• Butorphanol

• Dexmedetomidine

• Hydromorphone

• Acepromazine

• Midazolam

• Ketamine

• Carprofen, Robenacoxib
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Pre-medications

• Butorphanol • Midazolam
• Mixed opioid agonist-antagonist • Benzodiazepine
• Analgesic • Sedative, anxiolytic, muscle relax
• Dexmedetomidine • Ketamine
• Alpha 2 agonist • NMDA receptor antag; dissociative
• Sedative, anxiolytic, analgesic • Analgesic, sedative
• Hydromorphone • Carprofen
• Mu opioid receptor agonist • NSAID
• Analgesic, muscle relax, sedation • Analgesic
• Acepromazine • Robenacoxib
• Phenothiazine derivative • NSAID
• Sedative • Analgesic

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Plan - premeds

Analgesia
Torb, hydro, ketamine, NSAIDs, dexmed

Sedation/Narcosis Muscle
Dexmed, ace, ket, midaz Relaxation
Hydro, midaz

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Induction

• Propofol
• Short-acting, lipophilic, sedative-hypnotic, general anesthetic
• Sedative

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Plan – premeds + induction

Analgesia
Torb, hydro, ketamine, NSAIDs, dexmed

Sedation/Narcosis Muscle
Dexmed, ace, ket, midaz Relaxation
Propofol Hydro, midaz

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Maintenance

• Isoflurane
•Inhalant
general anesthetic

Sedation/ hypnosis

(propofol for TIVA)

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Plan – premed + induction + maintenance

Analgesia
Torb, hydro, ketamine, NSAIDs, dexmed

Sedation/Narcosis Muscle
Dexmed, ace, ket, midaz Relaxation
Propofol Hydro, midaz
Isoflurane

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Intraoperative pain

• Repeat doses of analgesic pre-meds

• Especially for longer procedures

• Local / regional blocks – lidocaine or bupivacaine - analgesic

• Splash or line block
• Testicular block
• Intraperitoneal lavage

• Continuous rate infusions (CRI) of analgesics

• MLK, lido, fentanyl, etc.

• NSAIDs
• Pre-operative if using IVF and health patient
• Post operative for 3-5 days

• Continue to assess and control post operatively in clinic

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Plan

Analgesia
Torb, hydro, ketamine, NSAIDs, dexmed
Local blocks, CRIs

Sedation/Narcosis Muscle
Dexmed, ace, ket, midaz Relaxation
Propofol Hydro, midaz
Isoflurane

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Local anesthesia for S/N

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Another great resource

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Monitoring / supportive

• ETCO2
• EKG
• Pulse oximetry
• Blood pressure
• Temperature
• Anesthetic depth
• Maintenance agent level

• Airway protection
• Oxygen
• Warming devices
• Intravenous fluids
• Eye lubrication
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No fancy monitor? Techs to the rescue!

• ETCO2 – monitor resp rate and effort, ambu bag

• EKG – auscult periodically, palpate pulse
• Pulse oximetry – assess capillary perfusion
• Blood pressure – pulse strength, capillary perfusion
• Temperature - manual
• Anesthetic depth – manual (eye position, palpebral reflex,
jaw tone, stimulation response)

• Airway protection & Oxygen – room air

• Warming devices – microwaved fluid bags, socks, towels,
heating pad

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Anticipate

• Always be prepared to deal with the most COMMON

complications associated with anesthesia

• HYPOTENSION
• HYPOTHERMIA
• HYPOVENTILATION

(also keep your common surgical

complications in mind!  )

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Packet review

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Telazol in the U.S. (SA)

• Used primarily in high volume, low cost, shelter or spay-

neuter settings in a “cocktail” with other drugs and an atropine
pre-med

• Minimal analgesia, moderate sedation & musc relax

• short duration

• “TTDex” = butorphanol, telazol, dexmedetomidine

• Additional coverage on all three points of triad

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References

• U.S. Army Veterinary Medical Standardization Board, Army

Public Health Center

• American Society of Anesthesiologists (ASA)

• The American Animal Hospital Association (AAHA)

www.aaha.org

• Plumb’s Veterinary Drug Handbook

• Vet track lecture notes (Giles Principles of Pain Management)

• Vet school anesthesia notes

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Questions? / Group Discussion

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