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Proceeding of the NAVC

North American Veterinary Conference
Jan. 8-12, 2005, Orlando, Florida

Reprinted in the IVIS website with the permission of the NAVC

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Published in IVIS with the permission of the NAVC
Veterinary Technician
ANESTHETIZING THE EMERGENCY PATIENT
Gregory R. Hanson, RVT, VTS (Anesthesia)
Veterinary Medical Teaching Hospital
University of California, Davis, CA
EMERGENCY: A sudden, urgent, unexpected occurrence
requiring immediate action.
Patients present to veterinary clinics for a variety of
“emergency” circumstances. These patients exhibit a wide
range of clinical signs from stable to critically ill. Triage allows
the health care team to assess the patient and prioritize
treatment. Many of these patients will require anesthesia for
either diagnostic or therapeutic procedures. Time is of the
essence during an emergency crisis, efficient use of time and
resources are crucial to the well being of the patient.
Anesthesia can produce significant depression and
compromise of the cardiopulmonary system. The combination
of a stressed, physiologically unstable patient coupled with
the depressant effects of anesthesia can be disastrous for the
patient
ASSESSMENT AND STABILIZATION
Before the administration of anesthesia can be considered
the patient must be assessed. What do we have to work with
and what are our concerns? Initial assessment is focused on
the major body systems: respiratory, cardiovascular,
neurological and urogenital. Airway, Breathing and
Circulation is the primary focus of the initial assessment and
treatment. The emergency patient’s basic requirements from
the cardiopulmonary system are the same as the non-
emergency patient. The end-point is tissue perfusion that will
facilitate oxygenation and carbon dioxide extraction. Meeting
this basic need is the focus for the initial triage and
stabilization of the patient. The emergency patient’s
physiology has been stressed and compensatory
mechanisms may be unable to compensate further to
maintain homeostasis when anesthesia drugs are
administered. Therefore, the goal of proper stabilization prior
to anesthesia is to yield a patient that is more likely to tolerate
the anesthesia/operative period without substantial
decompensation. Care must be taken to avoid rushing an
unstable patient into an anesthesia and/or surgical
procedure.
For the initial assessment an “A, B, C” approach may assist
the anesthetist to prioritize and organize the assessment.
“A” for airway, “B” for breathing, and “C” for circulation. Does
the patient have control of its airway and is it able to
adequately breathe? Will the anesthetist be able to establish
and maintain a patent airway once anesthesia has been
induced? Respiratory pattern and effort should be evaluated.
Auscultation of the chest will offer information about both
cardiac and respiratory function. Cardiac murmurs,
arrhythmias or dull heart and lung sounds as well as
pulmonary crackles or wheezes may be indications of
abnormalities that could evolve to life threatening
complications. If there is any doubt about pulmonary function,
further evaluation should be pursued. Thoracic radiographs
may help to rule out or diagnose pulmonary complications
such as pneumonia or pleural space problems such as
pneumothorax, pleural effusion, or space occupying lesions.
However, care must be taken not to jeopardize patient safety
for the sake of a diagnostic radiograph. Often a chest tap will
be diagnostic of fluid or air in the chest. Mucous membrane
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color can be assessed, however it should be remembered
that cyanosis is an insensitive indicator of hypoxemia. Pulse
oximetry is an appropriate tool to rule out hypoxia. Oxygen
carrying capacity should be included in the assessment by
evaluating percent hematocrit and hemoglobin. Oxygen
supplementation should be provided to any patient exhibiting
signs of respiratory distress.
Respiratory abnormalities seldom improve and will more
then likely worsen with the administration of anesthesia
drugs. Therefore, abnormalities that will affect respiration and
oxygenation should be normalized as much as possible prior
to anesthesia induction. If the ability to establish and maintain
a patent airway during anesthesia is in question, contingency
plans to provide and maintain the airway should be
established. If additional supplies and personnel are needed,
they should be gathered prior to the induction of anesthesia.
Circulation is the C part of the A,B,C s. Evaluation of the
system will provide the anesthetist with information used to
determine the patient’s ability to adequately perfuse tissues.
Mucous membrane color and texture, capillary refill time,
pulse; rate, rhythm and quality, along with blood pressure will
provide information regarding the cardiovascular system’s
status. It is important to look at all of the parameters and not
just one, to evaluate the system. Once again, if the
cardiovascular system is unstable or performing
inadequately, that condition will only worsen with the
administration of anesthetic drugs. Prior to induction of
anesthesia, intravenous catheterization and fluid
administration, in addition to oxygen administration may be
required to initially stabilize the cardiopulmonary system and
assure adequate oxygen delivery and tissue perfusion.
An evaluation of the neurological system must be included
in the initial exam. Anesthesia is the reversible depression of
the CNS and the anesthetist relies on the evaluation of this
system to assess depth of anesthesia through reflexes and
muscle tone. Decreased mental status and/or the inability to
ambulate may indicate significant central nervous system
problems. The development of a safe and effective
anesthesia plan requires the anesthetist know the baseline
status of the patient’s CNS prior to the administration of
anesthesia drugs. The administration of various anesthetic
drugs to a patient with an altered mental state can result in
significant changes in intracranial pressure that may
exacerbate the effects of head trauma or brain disease. The
patient with spinal injury may require additional
musculoskeletal support from a backboard or other device to
avoid further damage to the spine during or after anesthesia
induction when the muscles have relaxed and no longer
support the skeletal system.
The urogenital system is initially evaluated to assure the
patient has a bladder and is able to urinate, but this tells little
about renal function. Anesthesia effects renal function either
through decreased glomerular filtration or decreased renal
blood flow. Renal function can have an effect on the
response to anesthetic agents. Azotemia can affect the CNS
sensitivity to anesthetic agents. Renal insufficiency can affect
acid-base status of the patient, resulting in a concurrent
increase in serum potassium as well as decrease in the drug
dose required to produce anesthesia. Hyperkalemia is a
possibility in patients with renal insufficiency, ruptured urinary
bladder or urethral obstruction. Patients with serum
potassium levels greater then 5.5 mEq/L should not be
anesthetized until potassium levels can be reduced. If the
patient already has some degree of renal disease and
experiences hypotension and/or hypovolemia during
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The North American Veterinary Conference – 2005 Proceedings

anesthesia, the likelihood of exacerbating the renal disease is
increased.
Blood may be collected at the time of IV catheterization to
establish a baseline assessment of hematocrit, total solids,
blood glucose, electrolytes and blood urea nitrogen. The
more knowledge the anesthetist can gather about the
patient’s physiological status, the better the anesthetist can
plan for care and support during anesthesia.
ANTICIPATED PROBLEMS
Often an emergency patient’s physiological reserves and
compensatory mechanisms are reduced resulting in a less
stable patient that is more prone to anesthetic complications.
Fortunately, there are very few situations in which a patient
must be anesthetized before it can be stabilized. For any
patient, anesthesia always has the potential for deleterious
effects, but the emergency patient is more volatile and tends
to experience rapid physiological changes during anesthesia.
Hypotension, hypovolemia, hypoventilation, hypoxia,
hypothermia and pain are just a few of the potential problems
for the emergency anesthesia patient.
The development of contingency plans for the avoidance of
or treatment of each anticipated problem will help to reduce
the anesthesia risk and expedite the anesthetist’s intervention
when complications are detected and thus increase the
likelihood of an uneventful anesthesia outcome.
ANESTHESIA DRUG PLAN
The selection of anesthesia drugs used to provide
anesthesia care for the emergency patient will require the
anesthetist have a good working knowledge of the operative
risk associated with the current physical status of the patient,
the procedure to be performed and the resources available to
the anesthetist. The administration of anesthetic drugs to
hypovolemic patients is well documented to cause very
significant decreases in cardiac output and mean arterial
blood pressure, tissue perfusion, oxygen delivery and
increased oxygen extraction. The inhaled anesthetic agents
have the most profound effect. The inhaled anesthetic agents
all produce a dose dependent cardiovascular and respiratory
depression that can render a hemodynamically challenged
patient unable to perfuse vital organs, potentially leading to
inadequate oxygen delivery resulting from hypotension/
hypovolemia. That is not to say an inhaled anesthetic should
not be used in these patients, rather it should be used with
caution and at a decreased dose. Alternatively, the use of
opioids in the drug plan is known to provide good analgesia,
reduce the need for higher doses of other anesthetic drugs
such as the inhaled agents, and promote a more stable
hemodynamic environment for the patient. Opioids will
reduce cardiac output due to increased vagal tone, but this is
responsive to anticholinergic therapy. Benzodiazepines are
also effective in reducing the dose of other anesthetic drugs,
while producing minimal cardio-pul-monary depression.
Adequate anesthesia and analgesia that produces the least
detrimental effects on the cardiopulmonary system is only
one goal of the anesthesia drug plan. The fragility of
hemodynamics for the emergency patient supports the use of
a balanced anesthesia technique. Balanced anesthesia
techniques use smaller doses of multiple drugs that will
produce less deleterious effects than larger doses of a single
drug such as an inhaled anesthetic agent. The use of other
support drugs such as local anesthetics, crystalloids, colloids,
and sympathomimetics will aid the anesthetist in the support
of the patient and help to counteract the harmful effects that
anesthesia drugs can promote. The ultimate goal of the
anesthesia drug plan is to maintain physiological
homeostasis or a “normal stable” physiological environment,
while rendering the patient unconscious, immobile, and pain
free. Listed below are common anesthetic drugs and their
effects on the cardiovascular system.

Drug Heart Contractility Cardiac Blood Pressure Central Venous Myocardial Oxygen
Rate Output Pressure Consumption
Alpha 2 agonists p NC-p p Initial n, then p n NC-n
Anticholinergics n n n NC-n p n
Barbiturates n p p p p NC-n
Benzodiazepines NC NC NC NC NC p
Dissociative drugs n n n n p n
Etomidate NC-n NC-p NC-p NC-p NC-p NC-n
Inhaled Anesthetic p p p p p p
agents
Opioids p NC-p p NC-p p NC
Phenothiazines n p n p p NC-n
Propofol NC-n p p p p NC-n
n = Increase, p + Decrease, NC = No change

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Veterinary Technician
PHYSIOLOGICAL MONITORING PLAN
How will you know if your patient is adequately supported
during anesthesia? The purpose of patient monitoring is to
provide information that can be used by the anesthetist and
allow for prudent decisions to maximize patient support and
safety. Patient monitoring should be designed to allow the
anesthetist to recognize problems at the earliest stages and
respond before these early complications can evolve into an
anesthesia crisis. This is especially important in the
hemodynamically challenged emergency patient. When
designing the monitoring plan, a systemic approach to
monitoring is effective. Monitoring of the cardiovascular
system is a priority since most anesthesia drugs produce
significant cardiopulmonary depression. The anesthetist must
be able to monitor cardiovascular performance and respond
to meet the needs of the patient. Cardiovascular parameters
that will assist the anesthetist include: mucous membrane
color, CRT, heart rate and rhythm, pulse quality and arterial
blood pressure as well as hematocrit and total solids. The
other component of the cardiopulmonary system that requires
the anesthetist’s attention is the respiratory system.
Respiratory monitoring is more then just respiratory rate,
effort and estimated volume. Emergency patients frequently
experience difficulty adequately delivering oxygen to tissues.
This may be due to in part to shock, poor hemodynamic
performance, poor pulmonary performance or a combination
of all. Respiratory parameters that will assist the anesthetist
include: respiratory rate and effort, estimated or measured
tidal volumes, end-tidal carbon dioxide, percent arterial
hemoglobin oxygen saturation, hematocrit and blood gas
analysis.
Laboratory blood analysis during the course of anesthesia
could also include blood glucose, electrolyte, acid base
status, colloid-oncotic pressure and lactate threshold.
Anesthetists spend much of their time in direct contact with
the patient. We use our senses to evaluate the patient and
analyze the data we perceive through sight, sound and touch.
We can augment that information with the addition of
electrical and mechanical equipment to give the anesthetist
additional information. When we use additional devices to
assist our monitoring we must also assure the information
provided is accurate. In order to do this, we must ensure the
equipment is dependable and in good working order. The
anesthetist must also have a clear understanding of both the
equipment and the significance of the information provided by
the equipment. The additional information provided by the
monitors is intended to make the anesthetist’s job easier and
provide a more complete picture of the patient’s physiological
status. If the data provided by the monitoring equipment is
unreliable then it only serves to misinform, distract and
confuse the anesthetist. When evaluating the patient, it is
important to look at the whole and not just one or two
parameters. This means the anesthetist must not only focus
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on the monitors attached to the patient, but we must also
focus on the patient itself and evaluate all the data we have
available. These points are true for the any patient during the
anesthesia period, but they are especially significant for the
emergency patient that often is not be as stable as the
“average” anesthesia patient.
For a table of hemodynamic parameters and expected
patient values during anesthesia, please refer to “Advanced
Anesthesia Monitoring – Cardiovascular Performance”
The patients that present to veterinary clinics for
emergency treatment frequently require anesthesia to
facilitate their treatment. These patients often are
experiencing pain and suffer from various forms of shock or
other hemodynamic challenges. It is not only appropriate to
stabilize these patients and provide pain therapy prior to the
induction of anesthesia, but it is certainly in the best interest
of the patient. The stabilized patient is more likely to better
tolerate the anesthesia period without further detriment then
the unstable patient that is further challenged by the
administration of anesthesia drugs and must attempt to
compensate for their cardiopulmonary depressant effects.
A safe anesthesia plan for emergency patients should be
developed utilizing anesthetic drug protocols that will
minimize the hemodynamic challenges and maximize patient
support and comfort. The anesthesia plan must also include a
monitoring plan that is designed to alert the anesthetist to
problems at the early stages and will assist the anesthetist to
provide appropriate anesthesia care. One of the most
important members of the patient care team for the
emergency patient is the anesthetist. The knowledge, skills,
and diligence of the experienced anesthetist will provide the
necessary care and support to significantly reduce morbidity
and mortality for the emergency patient.
REFERENCES
1. Perkowski SZ, Anesthesia for the emergency small
animal patient. The Veterinary Clinics of North America –
Small Animal Practice - May 2000.
2. Holden DJ, Hammond R, Anaesthesia and analgesia for
the critical patient. Manual of canine and feline
emergency and critical care, British Small Animal
Association.
3. Haskins SC, Monitoring and support. The Veterinary
Clinics of North America – Small Animal Practice –
March 1992.
4. Pascoe PJ, Perioperative Pain Management. The
Veterinary Clinics of North America – Small Animal
Practice – July 2000.
5. Seeler DC, Anesthesia for compromised patients.
Veterinary Emergency and Critical Care Medicine,
Murtaugh and Kaplan.
6. Haskins SC, Monitoring the anesthetized patient.
rd
Veterinary Anesthesia 3 edition, Lumb and Jones 1996.
7. Hall LW, Clarke KW, Trimm CM, Patient monitoring and
clinical measurement. Veterinary Anesthesia 10th Edition.