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

References

1. WHO Glossary

2. UCLA Dept. Epidemiology: Definitions

3. Molins, Ricardo A. (2001). Food irradiation: principles and applications. Wiley-IEEE. p. 23. ISBN 978-0-471-35634-9.

4. Brown, Amy Christian (2007). Understanding Food: Principles and Preparation (3 ed.). Cengage Learning. p. 546. ISBN 978-0-495-10745-3.

5. No bugs please, this is a clean planet!". European Space Agency. 30 July 2002. Retrieved 7 August 2014.

6. Guidance for Industry: Biological Indicators". United States Food and Drug Administration. 4 October 2007.

7. Guidance for Industry: Sterile Drug Products Produced by Aseptic Processing" (PDF). United States Food and Drug Administration. September 2004.

8. Steam Sterilization Principles". STERIS Life Sciences. November 2013.

9. Decontamination and Sterilization". NIH.

10. Casolari, A. "FOOD STERILIZATION BY HEAT". Liberty Knowledge Reason.

11. Alberta Health and Wellness" (PDF). Health.gov.ab.ca. Retrieved 2010-06-25.

12. Dental Volume 1 - Dentist training manual for military dentists

13. Thiel, Theresa (1999). "Sterilization of Broth Media by Tyndallization" (PDF). Science in the Real World. Retrieved 2007-03-06.

14. Zadik Y, Peretz A (Apr 2008). "The effectiveness of glass bead sterilizer in the dental practice". J Isr Dent Assoc 25 (2): 36–9. PMID 18780544.

15. http://www.CDC.gov/OralHealth/InfectionControl/faq/bead.htm 2008-09-11

16. Substitute Sterilants under SNAP as of September 28, 2006" (PDF). Retrieved 2010-06-25.

17. "Sterilization/Aeration Equipment". Solutions.3m.com. Retrieved 2010-06-25.

18. Unique solutions for infection control, sterile processing, SPD, and sterilization: EtO Sterilization Solutions". SteriCert. Retrieved 2010-06-25.

19. Micro-dose sterilization method

20. IARC Vol 60" (PDF). Retrieved 2010-06-25.

21. "NIOSH: Documentation for Immediately Dangerous to Life or Health Concentrations (IDLH) / NIOSH Chemical Listing and Documentation of Revised IDLH Values (as of 3/1/95) - intridl4". Cdc.gov. Retrieved 2010-06-25.

22. ATSDR - MMG: Ethylene Oxide". Atsdr.cdc.gov. 2007-09-24. Retrieved 2010-06-25.

23. "Hospital eTool: Central Supply Module". Osha.gov. Retrieved 2010-06-25.

24. Görsdorf S, Appel KE, Engeholm C, Obe G.; Nitrogen dioxide induces DNA single-strand breaks in cultured Chinese hamster cells: Carcinogenesis. 1990.

25. "Mechanism Overview, June 2012" (PDF). noxilizer.com. Noxilizer, Inc. Retrieved 2 July 2013.

26. "Noxilizer Contract Sterilization Services". noxilizer.com. Noxilizer, Inc. Retrieved 2 July 2013.

27. CRC Handbook of Chemistry and Physics, 76th Ed. 1995.

28. http://www.cdc.gov/niosh/idlh/intridl4.html

29. "Sterrad NX". Retrieved 25 March 2015.

30. "Guidelines for Disinfection" (PDF). Center for Disease Control. 2008.

31. "29 CFR 1910.1000 Table Z-1". Occupational Safety and Health Administration. Retrieved 25 March 2015.

32. "MAUDE - Manufacturer and User Facility Device Experience". Accessdata.fda.gov. Retrieved 2010-06-25.

33. "Occupational Safety and Health Guideline for Hydrogen Peroxide". Osha.gov. Retrieved 2010-06-25.

34. "ATSDR - MMG: Hydrogen Peroxide". Atsdr.cdc.gov. 2007-09-24. Retrieved 2010-06-25.

35. "Cleared Sterilants and High Level Disinfectants with General Claims for Processing Reusable Medical and Dental Devices". United States Food and Drug Administration. March 2015.

36. Bauman, PA; Lawrence LA; Biesert L; Dichtelmüller H; Fabbrizzi F; Gajardo R; Gröner A; Jorquera JI; Kempf C; Kreil TR; von Hoegen I; Pifat DY; Petteway SR Jr; MCai K (July 2006). "Critical factors influencing prion inactivation by sodium hydroxide.". Vox Sang 91 (1): 34–40. doi:10.1111/j.1423-0410.2006.00790.x. PMID 16756599.

37. Trends in Radiation Sterilization of Health Care Products, IAEA, Vienna,24 September 2008

38. Information Notice No. 89-82: RECENT SAFETY-RELATED INCIDENTS AT LARGE IRRADIATORS

39. Bharati, S; Soundrapandian C; Basu D; Datta S (2009). "Studies on a novel bioactive glass and composite coating with hydroxyapatite on titanium based alloys: Effect of γ-sterilization on coating". J Eur. Ceram. Soc. 29 (12): 2527–35. doi:10.1016/j.jeurceramsoc.2009.02.013.

40. "Guidance for Industry, Sterile Drug Products Produced by Aseptic Processing — Current Good Manufacturing Practice" (PDF). U.S. Department of Health and Human Services. 2004

41. "Guidance for Industry: Sterile Drug Products Produced by Aseptic Processing" (PDF). United States Food and Drug Administration. September 2004.