anestesia por yves moens

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


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


General anaesthesia riskGeneral anaesthesia risk

Horses: 1%Human: 0,001%Small animals: 0,1%

Horses: 1%Human: 0,001%Small animals: 0,1%


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


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


IMPORTANCE OF OXYGENIMPORTANCE OF OXYGEN

HYPOVENTILATION

HYPERCAPNIAHYPOXEMIA

INSUFFICANCY OF O2 IN THE CENTRAL NERVOUS SYSTEM

RESPIRATORY ARREST

CARDIAC ARREST

ANAESTHESIAWITHOUT OXYGEN


IMPORTANCE OF OXYGENIMPORTANCE OF OXYGEN

HYPOVENTILATION

HYPERCAPNIANORMOXEMIA

ANAESTHESIAWITH OXYGEN


Administer oxygenAdminister oxygen

O2 thankConcentratorO2 thankConcentrator


Breathing system

patient

Bain system

Fresh gaz flow

100 mL/Kg/minwith minimum 1L


2

Circle system


Administer IV drugsAdminister IV drugs

IV catheterIV catheter


Perform CardioPulmonary Resuscitation

Perform CardioPulmonary Resuscitation

A AIRWAYB BREATHINGC CIRCULATIOND DRUGSE ECGF FLUIDS

A AIRWAYB BREATHINGC CIRCULATIOND DRUGSE ECGF FLUIDS


Perianaesthetic considerationsPerianaesthetic considerations

Hypothermia preventionHypovolemia preventionProtection of the cornea

Hypothermia preventionHypovolemia preventionProtection of the cornea


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


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


surgery=

pain/nociception


pain/nociception

stress situation


pain/nociception & stress

morbidity

mortality


Goals of general anaesthesia for surgical procedure

Goals of general anaesthesia for surgical procedure

unconsciousness

analgesia myorelaxation


QuickTime™ and aPhoto - JPEG decompressor

are needed to see this picture.how to choose the most adapted

strategy?


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


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


ASA classificationASA classification

emergencyE

very highV

highIV

moderateIII

lightII

minimalI


Aim of anaesthesiaAim of anaesthesia

Surgical procedureor

No nociception expected

Surgical procedureor

No nociception expected


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’)


EnvironmentEnvironment

Quiet?Quiet?


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


Anaesthetic protocol

unconsciousness



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


Preemptive analgesiaPreemptive analgesia

injury

hypersensitivityfrom Woolf & Chang Anesth Analg 1993 77: 362-79



injury


a



injury


pa


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



yesLocal anesthyesN2O

yesyesHalogenated yesyesPropofol

yesdependsDissociative yesyesBarbiturates

yesOpioids yesyesAlpha2agon yesBenzodiaz yesPhenothiaz

Myorelaxa-tion

Uncons-ciousness

Analgesia DRUGSproperties


ASA classificationASA classification

emergencyE

very highV

highIV

moderateIII

lightII

minimalI


Analgetic strategy during anaesthesiaAnalgetic strategy during anaesthesia

SYSTEMIC OPIOIDS

SYSTEMIC

α 2 AGONISTS

LOCAL ANESTHESICS

KETAMINE

BALANCED ANALGESIA

main

complementoryN2O


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


Drugs for tivaDrugs for tiva

short half life timenot accumulating short half life timenot accumulating


Context Sensitive Half LifeContext Sensitive Half Life

From http://dailymed.nlm.nih.gov



From Shafer, Anesthesiology 1991; 74:53



From Schafer, J Clin Anesth;, 1993


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


Intermittent boli techniqueIntermittent boli technique


Constant rate infusions (cri)Constant rate infusions (cri)


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


Where are the syringe pumps?Where are the syringe pumps?


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)


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?


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


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


Target Controlled Infusion (TCI)Target Controlled Infusion (TCI)


future: Closed-loop anaesthesiafuture: Closed-loop anaesthesia

? BIS-monitor

(bispectral edge-eeg baseg)


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


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


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


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


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


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”


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



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


TIVATIVA

Propofol + Fentanyl-8-16mg/kg/hr + 2-20 µg/kg/hr

Propofol + Fentanyl-8-16mg/kg/hr + 2-20 µg/kg/hr


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


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!


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


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


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



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

anestesia por yves moens

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