Kara Blaha October 1st 2008

8/14/2019 Kara Blaha October 1st 2008

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Kara Blaha

October 1st 2008


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3 month old female intact Pug

Presented on Emergency to Ophthalmology Service on 3-19-08 for the evaluation of an acutely enlarged, swollen

eye.


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OS wnl, lateral strabismus

OD Buphthalmic

Enlarged palpebral tissue

Hyperemic conjuctiva Neovascularization

Granulation Tissue

Ocular Pressure=58

Exposure keratitis

Retinal detachment (ultrasound)


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QAR, Depressed

HR-140, no murmur, arrhythmia, crt


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Primary Glaucoma

Enophthalmitis

Surgical Enucleation,

scheduled for following

day.

Admitted to Cornell INC Cosopt OD q 8hrs

Neopolybacitracin OD q

6 hrs Buprenorphine 0.015mg

SC q 6 hrs-prn.

Plan


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Physical Examination WNL* (140bpm)

Brachycephalic, referred upper airway sounds CBC/Chemistry

WBC-23.6 thou/uL (6.2-14.4) Segmented Neutrophils-18.6 thou/uL (3.4-9.7) Monocytes-2.6 thou/uL (0.1-1) Eosinopenia- 0.0 thou/uL

QATS PCV-32 TS-7.2

BUN-5-15 Glucose-121

ASA I*


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Premedication (2:00pm) Previously received 2 doses of buprenorphine Meloxicam Catheter placement

Induction (2:10pm) Thiopental-32.5mg IV

Normal intubation

Monitoring equipment Pulse Oximetry

ECG Cardell (indirect blood pressure) Temperature


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Shortly after induction

Coughing, gagging Heart rate accelerates to 180bpm

Respirations irregular, many assisted

Appeared to be getting light


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Propofol-5mg IV

Hydromorphone-0.8mg IV (2:15pm) 0.28mg/kg dose (high)

CARDIOPULMONARY ARREST!!!!!!!

Within minutes.. Spontaneous breathing stops, assisted breaths, abnormal

chest compliance

MAP decreases to 45 mmHg

Pulse rate rapidly decreases (180 to 30)

Asystole


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Loss of Consciousness

Absence of spontaneous ventilation

Absence of heart sounds on auscultation Absence of palpable pulses

NB~ CRT and mucus membrane color should not be used to define

CPA!!!

Difficult to accurately record all patients that experience CPA.

Survival rate to discharge

4% dogs (Incidence 169) 9.6% cats (incidence 52)


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Non-anesthetic related CPA

Severe metabolic/electrolyte derangements Sepsis

Cardiac disease/failure

Pulmonary disease

Neoplasia

Coagulopathies

Toxicities

Multisystemic trauma Brain injury/trauma

Systemic InflammationPlunkett & McMichael, 2008


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Anesthetic Related CPA 0.5% of dogs

0.4% of cats Technical Errors

Incorrect dosages Incorrect machine setup Mechanical failure

Pathologic Errors Cardiac

Arrhythmias Hypotension

Respiratory inadequacy Hypoxemia Hypercapnea

Idiopathic Drug ResponsesCole et el, 2003


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Excessive Depth of Anesthesia

Changes in body position Hemorrhage

Perisurgical antibiotics

Anaphylaxis


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Five Hs Hypovolemia

Hypoxia

Hydrogen (acidosis)

Hyper/Hypokalemia

Hypothermia Five Ts

Tablets (overdose)

Tamponade

Tension pneumothorax Thrombosis of coronary arteries

Thrombosis of pulmonary arteriesCole et el, 2003


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Studied 175 anesthetic deaths in 117 UK veterinary

centers over 2 years Specifically cats

An increase in ASA category (I-II to ASA III and ASA III

to ASA IV-V) resulted in a three-fold increase in chance of

death.

An emergency procedure (ASA E) is 1.6 times more likely

to result in death than an urgent procedure.

Very small cats (


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Circulation Thoracic Pump Theory

Medium to large animals

Cardiac Pump Theory Small animals (


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Specific indications

Failure of External chest compressions recognized within 2-5 minutes

Large animals (>20kg)

Penetrating chest wounds

Thoracic trauma

Diaphragmatic hernia

Pericardial effusion

Hemoperitoneum Intraoperative arrest

Plunkett &McMichael, 2008


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Asystole

Pulseless electrical activity (PEA) Bradycardia

Ventricular Tachycardia

Ventricular Fibrillation


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Most common arrest rhythms in dogs and cats

CPCR only effective treatment DO NOT attempt defibrillation shock

Medical treatment has not been associated with increased

survival time to discharge

http://commons.wikimedia.org/wiki/Image:EKG_A

systole.jpg


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Apparently normal heart rate and rhythm on ECG

No myocardial contraction

http://www.austinheartbeat.com/images/ventfib2.gif


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Increased vagal tone

Hypothermia Increased intracranial pressure

Iatrogenic

Hypoglycemia

Plunkett & McMichael, 2008

www.learnwell.org/sb.gif


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Ectopic pacemaker in ventricular myocardium or Purkinjesystem

Treat underlying condition Many etiologies:

Hypoxia Pain

Ischemia Sepsis Electrolyte changes Trauma Pancreatitis GDV Primary cardiac disease


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Unorganized and asynchronous excitation of ventricular

myocardium Decreased cardiac output

Defibrillation is treatment of choice

7 J/kg for patients 15kg

Deliver only one shock then resume chest compressions for

2 minutes before reassessing.

www.emedu.org/ecg/images/vf_1.jpg


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Fluids

Medications

Routes of administration

Central line Peripheral IV catheter

Interosseous catheter

Intratracheal


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Good choice if patient is known to be hypovolemic

Use carefully in euvolemic patients

Crystalloids

Shock dose (90 ml/kg) in dehydrated patients 10-20ml/kg in euhydrated patients

Colloids

Hetastarch- 2-5ml/kg as bolus


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Epinephrine

Vasopressin Atropine

Amiodarone

Lidocaine Mannitol

Reversal agents

Nalaxone Flumazenil

atipamezole


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Mixed adrenergic agonist

Administered mainly for2-receptor stimulation in CPA. Peripheral arteriolar vasoconstriction

Unwanted 1 effects

Increases myocardial oxygen demands Intramyocardial arteriolar vasoconstriction

0.1 mg/kg IV, IO

Repeat every 3-5 minutes Maximum 3 doses


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Nonadrenergic endogenous pressor peptide

Recommended to be used in place of or in combinationwith Epinephrine

Ventricular tachycardia

Ventricular fibrillation

PEA

0.2-0.8 U/kg IV, IO

Repeat every 3-5 minutes or alternate with Epinephrine


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Anticholinergic parasympatholytic

Muscarinic receptors Increases heart rate and systemic vascular resistance

Vagolytic

Asystole PEA

0.04 mg/kg IV

Repeated every 3-5 minutes Maximum 3 doses


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Antiarrhythmic agent

Medication of choice for refractory ventricular fibrillation Atrial Fibrillation

Ventricular Tachycardia

5.0 mg/kg IV, IO over 1o minutes Repeat dose 2.5 mg/kg after 3-5 minutes


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Antiarrhythmic agent

Sodium channel blocker Alternative to Amiodarone

2.0-4.0 mg/kg IV, IO (dogs)

Use cautiously in cats, 0.2 mg/kg IV, IO, IT Do not give if planning to Defibrillate!

Increases defibrillation threshold

Decreases myocardial automaticity


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More treatable than many types of CPA

Overdoses of some anesthetics can be reversed

Opiod-Nalaxone

Benzodiazepine-Flumazenil

2 adrenergic agonist- Yohimbine, Atipamezole

ABCs of CPCR are already in place

Epinephrine

Been shown to be effective in treating anesthetic relatedCPA

Low dose 0.01 mg/kg IV, IO


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Monitoring

Oxygen Supplementation Permissive mild Hypothermia

IV fluids

Close monitoring of Peripheral Perfusion Lactate concentration

Urine output

Body temperature

Neurologic Monitoring

Nutritional Supplementation


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Airway assumed to be patent

Assisted breaths given at 10 bpm

Chest compressions initiated (Cardiac Pump)

Chest compliance abnormal-Thoracocentisis

Three doses of Epinephrine give (0.55mg), total of 1.65mg

Two doses of Atropine given(0.11mg), total of 0.22 mg

Endotracheal tube pulled, revealed mucus plug in lumen of

tube.

Two Subsequent reintubations

Continuous CPCR efforts..


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ROSC (Return of Spontaneous Circulation)

Sinus Rhythm!!!

Monitoring on Ventilator for an hour revealed steady sinus rhythm! Two doses of Nalaxone given (0.04mg each)

Mannitol CRI initiated (total 1.5 g) Osmotic agent Reflex cerebral vasoconstriction

So after a successful resuscitation, the owners elected euthanasia due tofinancial constraints

CPCR-$1000 After-care estimate-$3000

$1300-3600 (Waldrop et al, 2004)


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Uno, the

one eyed

pug


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Dr. Looney

Dr. Campoy, Tammy and many other anesthesiatechnicians

Drs. Luschini, Menard and Reiss and the entire ICU staff

Brian Murch ($$$)


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1. Brodbelt D.C. et al. Risk factors for anaesthetic-related death in cats: results fromthe confidential enquiry into perioperative small animal fatalitites (CEPSAF).BJA 2007: 99 (5)617-623.

2. Cole S. et al. Cardiopulmonary cerebral resuscitation in small animals-a clinicalreview (part 1). J Vet Emerg Crit Care 2002: 12(4) 261-267.

3. Cole S. et al. Cardiopulmonary cerebral resuscitation in small animals-a clinicalreview (part 2). J Vet Emerg Crit Care 2003: 13(1) 13-23.

4. Collins T. & Samworth P. Therapeutic hypothermia following cardiac arrest: areview of the evidence. Nursing in Critical Care 2008: 13(3).

5. Plunkett S.J. & McMichael M. Cardiopulmonary Resuscitation in Small AnimalMedicine: An Update. J Vet Intern Med 2008: 22, 9-25.

6. Schmittinger C. et al. Cardiopulmonary resuscitation with vasopressin in a dog.Veterinary Anaesthesia and Analgesia 2005: 32, 112-114.

7. Waldrop J. et al. Causes of cardiopulmonary arrest, resuscitation management,and functional outcome in dogs and cats surviving cardiopulmonary arrest. J VetEmerg Crit Care 2004: 14(1): 22-29.


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Kara Blaha October 1st 2008