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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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