Felipe M.

Hi there Rachael
Thank you so much! I am very happy to hear you are enjoying the course. And well done for keeping your protocols up to date and refining them. I totally agree that is the best way to give your patients the best care. Fantastic to read this!

Great questions too, brachycephalics are certainly a big challenge from different sides. Let’s get to it:

– In terms of fasting, if I get to choose I would go for 6 hours. In dogs 4-6 hours is recommended, and given they are prone to regurgitation and may have hiatal hernia, 6 seems more advantageous to me. However no longer than that as it can increase the chances of regurgitation. Last meal I would recommend to be wet, and water always available.
– Adjunct medications, I personally like to give them omeprazole, at least the night before and definitely the morning of the anaesthetic. This helps protect the oesophagus from irritation if reflux happens during GA, but we need to keep in mind that no effects will happen until around 4h post administration (and will be sub-maximal as you need several doses for that). So giving it at the time of the regurgitation event will only help protect from effects of further reflux 4h down the line unfortunately. I also use maropitant before I give any drugs, bearing in mind that it does not protect against regurgitation, but in my head if we can reduce any peri-anaesthetic nausea, I hope this should decrease the chances of regurgitation too.
– Pre-anaesthetic medications: unless contraindicated, I do prefer alpha-2 agonists, at low doses (for the average animal, 2-3mcg/kg medetomidine diluted in 2-3mL and given slow to effect IV, or 4mcg/kg IM) and whichever opioid is adequate for the procedure. I am not against using acepromazine with them, but I usually only use this at low doses for mild sedation in hospitalisation (for anxiety I would prefer trazodone and for proper sedation I do medetomidine infusions).
– When regurgitation happens, if it’s at the end of the anaesthetic, I suction thoroughly (always check around the cuff of the ET tube!) and give the patient two or three doses of sucralfate in syrup form starting after recovery once safe to eat. However if it is mid anaesthetic, I suction thoroughly and then leave behind 0.6mL/kg of a 4.2% bicarbonate solution (Allison et al 2020) to buffer the oesophagus and prevent oesophagitis. This needs suctioning out before recovery to prevent possible aspiration. In accordance to that paper, I do not lavage any more as it does not change the end oesophageal pH.
– Extubating with cuff partially inflated is something I sometimes do, however it should never be done instead of a thorough suctioning of oesophagus, pharynx, mouth, larynx (in area where cuff is located) and nose. Good management of the airway reduces dramatically the chances of aspiration. Extubating with cuff partially inflated can be done in addition, however it does carry some risk as it can potentially over-stretch the larynx. If done gently, it should be fairly safe and may help. However I have to say that since I have escalated my airway prophylaxis in cases of reflux, this step is far less important to me. But as I said, it might still be worth adding this in some cases, to maximise safety just make sure you don’t over-stretch the larynx and if it doesn’t seem to come out easily, deflate the cuff straight away.

Hope this helps, but please let me know if you’d like me to elaborate further!

Thanks

Felipe

Hi there Rachael
Thank you so much! I am very happy to hear you are enjoying the course. And well done for keeping your protocols up to date and refining them. I totally agree that is the best way to give your patients the best care. Fantastic to read this!

Great questions too, brachycephalics are certainly a big challenge from different sides. Let’s get to it:

– In terms of fasting, if I get to choose I would go for 6 hours. In dogs 4-6 hours is recommended, and given they are prone to regurgitation and may have hiatal hernia, 6 seems more advantageous to me. However no longer than that as it can increase the chances of regurgitation. Last meal I would recommend to be wet, and water always available.
– Adjunct medications, I personally like to give them omeprazole, at least the night before and definitely the morning of the anaesthetic. This helps protect the oesophagus from irritation if reflux happens during GA, but we need to keep in mind that no effects will happen until around 4h post administration (and will be sub-maximal as you need several doses for that). So giving it at the time of the regurgitation event will only help protect from effects of further reflux 4h down the line unfortunately. I also use maropitant before I give any drugs, bearing in mind that it does not protect against regurgitation, but in my head if we can reduce any peri-anaesthetic nausea, I hope this should decrease the chances of regurgitation too.
– Pre-anaesthetic medications: unless contraindicated, I do prefer alpha-2 agonists, at low doses (for the average animal, 2-3mcg/kg medetomidine diluted in 2-3mL and given slow to effect IV, or 4mcg/kg IM) and whichever opioid is adequate for the procedure. I am not against using acepromazine with them, but I usually only use this at low doses for mild sedation in hospitalisation (for anxiety I would prefer trazodone and for proper sedation I do medetomidine infusions).
– When regurgitation happens, if it’s at the end of the anaesthetic, I suction thoroughly (always check around the cuff of the ET tube!) and give the patient two or three doses of sucralfate in syrup form starting after recovery once safe to eat. However if it is mid anaesthetic, I suction thoroughly and then leave behind 0.6mL/kg of a 4.2% bicarbonate solution (Allison et al 2020) to buffer the oesophagus and prevent oesophagitis. This needs suctioning out before recovery to prevent possible aspiration. In accordance to that paper, I do not lavage any more as it does not change the end oesophageal pH.
– Extubating with cuff partially inflated is something I sometimes do, however it should never be done instead of a thorough suctioning of oesophagus, pharynx, mouth, larynx (in area where cuff is located) and nose. Good management of the airway reduces dramatically the chances of aspiration. Extubating with cuff partially inflated can be done in addition, however it does carry some risk as it can potentially over-stretch the larynx. If done gently, it should be fairly safe and may help. However I have to say that since I have escalated my airway prophylaxis in cases of reflux, this step is far less important to me. But as I said, it might still be worth adding this in some cases, to maximise safety just make sure you don’t over-stretch the larynx and if it doesn’t seem to come out easily, deflate the cuff straight away.

Hope this helps, but please let me know if you’d like me to elaborate further!

Thanks

Felipe

Dear all

My name is Felipe and I am truly happy to welcome you to our advanced anaesthesia course. I am very excited to take this deep dive in techniques and scenarios that go way beyond the basic practice of anaesthesia and expand on those topics that would take us too far from the foundations of anaesthesia in a basic course. We will however be maintaining a solid connections with those principles and foundations to make sense of all these concepts and integrate them in your everyday practice.
Since I find a big part of my approach to anaesthesia is in the strategy and the reasoning and planning of the case and choice of drugs and techniques, we will also go through some scenarios that illustrate a couple of different ways of doing this. They are scenarios I have been asked about a lot, but I also found them excellent examples for different approaches. Hopefully all this makes sense in the sessions!

Any questions arising from the sessions, or anything you want to ask, please just pop it in the forum and I will answer all those. I will also put up a question of the week to elaborate a bit more on the material. Please feel free to answer it with whatever you think, even if it’s a wild guess! We are all here to learn together. However it is not required for you to do it, so no pressure. I will be answering these questions on the week after I upload them.

I would like to thank you for having chosen Vtx and myself for this journey, and welcome you to this course. I hope you enjoy it as much as I did making it.

Excellent!

F

Hi all

A massive thank you from me for choosing us for this journey. Respiratory disease certainly poses some of the biggest challenges for the anaesthetist, so it’s been a very interesting deep dive for me.

Hope you enjoyed it too, and found the information helpful!

Thanks again!

Felipe

Replying to Aileen D. 19/06/2024 - 12:02

Hi Aileen

Hope you are well.

Absolutely. In brachycephalic patients, reducing stress is a critical factor in avoiding respiratory complications in the peri-anaesthetic period. Animals that are anxious to come to the clinic or who are displaying onset of anxiety whilst hospitalised can certainly benefit from trazodone to minimise this and in turn avoid going into a self-perpetuating cycle of anxiety that many times will end up in an emergency situation.

Additionally, a more relaxed animal on presentation allows for an IV placement before any drugs are administered, which also shortens that period between sedative administration and airway control that we want to keep to the shortest possible. Trazodone has no clinically relevant effects on airway or ventilation, which suits our aims perfectly in these cases.

Hope this helps!

Felipe

Replying to scott@vtx-cpd.com 04/05/2024 - 16:59

Hi there Talia and Scott

This is a very interesting topic!

I personally have more experience with gabapentin due to being a more prevalent drug in veterinary prescriptions, but pregabalin has been shown to have additional sites of action and a better overall effect as an analgesic for chronic pain situations. For this reason I am starting to change over to pregabalin.

For cats, I would dose it at 2-5mg/kg PO BID (as it is eliminated more slowly than gabapentin, especially in cats). Some animals may see enough benefit from a SID regime, but most will need BID. I would not go above 5mg/kg BID normally, as especially above 7mg/kg doses cause incoordination and ataxia.

Hope this helps!

Felipe

Replying to Rachel L. 10/04/2024 - 17:50

Hi there Rachel

Not need to apologise at all! It’s a pleasure to help.

In case of hypotension, after reducing isoflurane if possible and adequate, I would likely choose noradrenaline for blood pressure management. The reason for this is that noradrenaline can be easily titrated to effect slowly, which would be very advantageous for this patient. I would start at 0.05mcg/kg/min and increase slowly by 0.05mcg/kg/min q5min, until normotensive.
The effect of ephedrine is not inadequate for this case, but the way it works as a bolus is much more sudden. An infusion can be made too, but usually is started after the initial bolus. Additionally, ephedrine is a bit less reliable in its effects.

So all in all, I think noradrenaline is a better fit for this patient, and I would still titrate with care!

Hope this helps!

Felipe