Kara Blaha

October 1st 2008

y 3 month old female intact Pug
y Presented on Emergency to Ophthalmology Service on 3-
19-08 for the evaluation of an acutely enlarged, swollen
eye.
y OS wnl, lateral strabismus
y OD
y Buphthalmic
y Enlarged palpebral tissue
y Hyperemic conjuctiva
y Neovascularization
y Granulation Tissue
y Ocular Pressure=58
y Exposure keratitis
y Retinal detachment (ultrasound)
y QAR, Depressed
y HR-140, no murmur, arrhythmia, crt<2
y RR-32, eupneic, increased referred airway sounds, pink
mucus membranes
y Temp-101.8
y Painful
 Plan
y Primary Glaucoma y Surgical Enucleation,
y Enophthalmitis scheduled for following
day.
y Admitted to Cornell INC
y Cosopt OD q 8hrs
y Neopolybacitracin OD q
6 hrs
y Buprenorphine 0.015mg
SC q 6 hrs-prn.
y Physical Examination
y WNL* (140bpm)
y Brachycephalic, referred upper airway sounds
y CBC/Chemistry
y WBC-23.6 thou/uL (6.2-14.4)
y Segmented Neutrophils-18.6 thou/uL (3.4-9.7)
y Monocytes-2.6 thou/uL (0.1-1)
y Eosinopenia- 0.0 thou/uL
y QATS
y PCV-32
y TS-7.2
y BUN-5-15
y Glucose-121

y ASA I*
y Premedication (2:00pm)
y Previously received 2 doses of buprenorphine
y Meloxicam
y Catheter placement
y Induction (2:10pm)
y Thiopental-32.5mg IV

y Normal intubation
y Monitoring equipment
y Pulse Oximetry
y ECG
y Cardell (indirect blood pressure)
y Temperature
y Shortly after induction……
y Coughing, gagging
y Heart rate accelerates to 180bpm
y Respirations irregular, many assisted
y Appeared to be “getting light”
y Propofol-5mg IV
y Hydromorphone-0.8mg IV (2:15pm)
y 0.28mg/kg dose (high)
CARDIOPULMONARY ARREST!!!!!!!
Within minutes……..
y Spontaneous breathing stops, assisted breaths, abnormal
chest compliance
y MAP decreases to 45 mmHg
y Pulse rate rapidly decreases (180 to 30)
y Asystole
y Loss of Consciousness
y Absence of spontaneous ventilation
y Absence of heart sounds on auscultation
y Absence of palpable pulses

¾ NB~ CRT and mucus membrane color should not be used to define
CPA!!!

y Difficult to accurately record all patients that experience CPA.

y Survival rate to discharge
y 4% dogs (Incidence 169)
y 9.6% cats (incidence 52)
y <6.4% humans Plunkett & McMichael, 2008
Waldrop et el, 2004
y Non-anesthetic related CPA
y Severe metabolic/electrolyte derangements
y Sepsis
y Cardiac disease/failure
y Pulmonary disease
y Neoplasia
y Coagulopathies
y Toxicities
y Multisystemic trauma
y Brain injury/trauma
y Systemic Inflammation
Plunkett & McMichael, 2008
y Anesthetic Related CPA
y 0.5% of dogs
y 0.4% of cats
y Technical Errors
y Incorrect dosages
y Incorrect machine setup
y Mechanical failure
y Pathologic Errors
y Cardiac
y Arrhythmias
y Hypotension
y Respiratory inadequacy
y Hypoxemia
y Hypercapnea
y Idiopathic Drug Responses
Cole et el, 2003
y Excessive Depth of Anesthesia
y Changes in body position
y Hemorrhage
y Perisurgical antibiotics
y Anaphylaxis
y Five H’s
y Hypovolemia
y Hypoxia
y Hydrogen (acidosis)
y Hyper/Hypokalemia
y Hypothermia
y Five T’s
y Tablets (overdose)
y Tamponade
y Tension pneumothorax
y Thrombosis of coronary arteries
y Thrombosis of pulmonary arteries Cole et el, 2003
y Studied 175 anesthetic deaths in 117 UK veterinary
centers over 2 years
y Specifically cats
y 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.
y An emergency procedure (ASA E) is 1.6 times more likely
to result in death than an urgent procedure.
y Very small cats (<2kg) were 16 times more likely to die
y Obtundation
y Hypothermia
y Bradycardia
y Hypotention
y Dilated, unresponsive pupils
y Changes in respiratory effort, rate, rhythm
y Gasping, agonal breathing

Plunkett & McMichael, 2008

y Circulation
y Thoracic Pump Theory
y Medium to large animals
y Cardiac Pump Theory
y Small animals (<15kg)

y Continuous and Uninterrupted

y Right lateral recumbancy
y 80-100 compressions per minute at 1:1 compression to relaxation
ratio.
y Change every 2 minutes
y Specific indications
y Failure of External chest compressions recognized within 2-
5 minutes
y Large animals (>20kg)
y Penetrating chest wounds
y Thoracic trauma
y Diaphragmatic hernia
y Pericardial effusion
y Hemoperitoneum
y Intraoperative arrest
Plunkett &McMichael, 2008
y Asystole
y Pulseless electrical activity (PEA)
y Bradycardia
y Ventricular Tachycardia
y Ventricular Fibrillation
y Most common arrest rhythms in dogs and cats
y CPCR only effective treatment
y DO NOT attempt defibrillation shock
y Medical treatment has not been associated with increased
survival time to discharge

http://commons.wikimedia.org/wiki/Image:EKG_A
systole.jpg
y Apparently normal heart rate and rhythm on ECG
y No myocardial contraction

http://www.austinheartbeat.com/images/ventfib2.gif
y Increased vagal tone
y Hypothermia
y Increased intracranial pressure
y Iatrogenic
y Hypoglycemia

Plunkett & McMichael, 2008

www.learnwell.org/sb.gif
y Ectopic pacemaker in ventricular myocardium or Purkinje
system
y Treat underlying condition
y Many etiologies:
y Hypoxia
y Pain
y Ischemia
y Sepsis
y Electrolyte changes
y Trauma
y Pancreatitis
y GDV
y Primary cardiac disease
y Unorganized and asynchronous excitation of ventricular
myocardium
y Decreased cardiac output
y Defibrillation is treatment of choice
y 7 J/kg for patients <15kg
y 10 J/kg for patient >15kg
y Deliver only one shock then resume chest compressions for
2 minutes before reassessing.

www.emedu.org/ecg/images/vf_1.jpg
y Fluids
y Medications

y Routes of administration
y Central line
y Peripheral IV catheter
y Interosseous catheter
y Intratracheal
y Good choice if patient is known to be hypovolemic
y Use carefully in euvolemic patients

y Crystalloids
y Shock dose (90 ml/kg) in dehydrated patients
y 10-20ml/kg in euhydrated patients
y Colloids
y Hetastarch- 2-5ml/kg as bolus
y Epinephrine
y Vasopressin
y Atropine
y Amiodarone
y Lidocaine
y Mannitol
y Reversal agents
y Nalaxone
y Flumazenil
y atipamezole
y Mixed adrenergic agonist
y Administered mainly for α2-receptor stimulation in CPA.
y Peripheral arteriolar vasoconstriction
y Unwanted α1 effects
y Increases myocardial oxygen demands
y Intramyocardial arteriolar vasoconstriction
y 0.1 mg/kg IV, IO
y Repeat every 3-5 minutes
y Maximum 3 doses
y Nonadrenergic endogenous pressor peptide
y Recommended to be used in place of or in combination
with Epinephrine
y Ventricular tachycardia
y Ventricular fibrillation
y PEA
y 0.2-0.8 U/kg IV, IO
y Repeat every 3-5 minutes or alternate with Epinephrine
y Anticholinergic parasympatholytic
y Muscarinic receptors
y Increases heart rate and systemic vascular resistance
y Vagolytic
y Asystole
y PEA
y 0.04 mg/kg IV
y Repeated every 3-5 minutes
y Maximum 3 doses
y Antiarrhythmic agent
y Medication of choice for refractory ventricular fibrillation
y Atrial Fibrillation
y Ventricular Tachycardia
y 5.0 mg/kg IV, IO over 1o minutes
y Repeat dose 2.5 mg/kg after 3-5 minutes
y Antiarrhythmic agent
y Sodium channel blocker
y Alternative to Amiodarone
y 2.0-4.0 mg/kg IV, IO (dogs)
y Use cautiously in cats, 0.2 mg/kg IV, IO, IT
y Do not give if planning to Defibrillate!
y Increases defibrillation threshold
y Decreases myocardial automaticity
y More treatable than many types of CPA
y Overdoses of some anesthetics can be reversed
y Opiod-Nalaxone
y Benzodiazepine-Flumazenil
y Α2 adrenergic agonist- Yohimbine, Atipamezole
y ABC’s of CPCR are already in place

y Epinephrine
y Been shown to be effective in treating anesthetic –related
CPA
y Low dose 0.01 mg/kg IV, IO
y Monitoring
y Oxygen Supplementation
y Permissive mild Hypothermia
y IV fluids
y Close monitoring of Peripheral Perfusion
y Lactate concentration
y Urine output
y Body temperature
y Neurologic Monitoring
y Nutritional Supplementation
y Airway assumed to be patent
y Assisted breaths given at 10 bpm
y Chest compressions initiated (Cardiac Pump)
y Chest compliance abnormal-Thoracocentisis
y Three doses of Epinephrine give (0.55mg), total of 1.65mg
y Two doses of Atropine given(0.11mg), total of 0.22 mg
y Endotracheal tube pulled, revealed mucus plug in lumen of
tube.
y Two Subsequent reintubations
y Continuous CPCR efforts……..
y ROSC (Return of Spontaneous Circulation)
y Sinus Rhythm!!!
y Monitoring on Ventilator for an hour revealed steady sinus rhythm!
y Two doses of Nalaxone given (0.04mg each)
y Mannitol CRI initiated (total 1.5 g)
y Osmotic agent
y Reflex cerebral vasoconstriction

y So after a successful resuscitation, the owners elected euthanasia due to

financial constraints……
y CPCR-$1000
y After-care estimate-$3000
y $1300-3600 (Waldrop et al, 2004)
Uno, the
one eyed
pug
y Dr. Looney
y Dr. Campoy, Tammy and many other anesthesia
technicians
y Drs. Luschini, Menard and Reiss and the entire ICU staff
y Brian Murch ($$$)
1. Brodbelt D.C. et al. Risk factors for anaesthetic-related death in cats: results from
the 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 clinical
review (part 1). J Vet Emerg Crit Care 2002: 12(4) 261-267.
3. Cole S. et al. Cardiopulmonary cerebral resuscitation in small animals-a clinical
review (part 2). J Vet Emerg Crit Care 2003: 13(1) 13-23.
4. Collins T. & Samworth P. Therapeutic hypothermia following cardiac arrest: a
review of the evidence. Nursing in Critical Care 2008: 13(3).
5. Plunkett S.J. & McMichael M. Cardiopulmonary Resuscitation in Small Animal
Medicine: 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 Vet
Emerg Crit Care 2004: 14(1): 22-29.