prep for clinical practice spot exam Flashcards

Question

Pollakiuria

Answer 1

abnormally frequent urination (little & often)

Answer 2

present of blood in urine Haematuria causes: Iatrogenic haematuria Pathological haematuria Genital sources (if voided) Do they have clinical signs associated with LUTD? Has bleeding been noticed from other sites? Trauma? Rodenticides? Blood in faeces? Pattern to urine pigmentation? Look for haemorrhage at other sites Abdomen, thorax, mucosae (especially mouth, axillae, groin) Palpate and assess kidneys for size, symmetry, discomfort Examine the external genitalia Gross “pigmenturia” red, brown or black urine 2. Urinalysis: positive haem 3 possible causes: Haematuria Haemoglobinuria Myoglobinuria Gross haematuria: >150 RBCs/hpf Occult haematuria: Positive Hb on dipstick >5 RBCs/hpf but not visibly pink Care re: interpretation if catheterised/cysto Both can be accompanied by clinical signs (stranguria, dysuria, pollakiuria)

Answer 3

urination at inappropriate sites

Answer 4

failure of urine production by the kidneys

Answer 5

reduction in urine production

Answer 6

Increase urine production

Answer 7

The presence of a component that imparts an abnormal colour to urine. Haemoglobinuria pink-red urine Intravascular lysis of RBCs Lysis of RBCs within the urinary excretory pathway e.g. USG <1.008, pH>7 Myoglobinuria rare in dogs and cats (seen more in horses) Extensive skeletal muscle damage/myopathies Creatinine Kinase

Answer 8

Urine Specific Gravity

Answer 9

Biochemistry Dipstick

Answer 10

1.015 to 1.045

Answer 11

1.035 to 1.060

Answer 12

Protein pH Blood/Haem Ketone Bilirubin Glucose also measures Leucocytes Nitrite Urobilinogen USG but these should not be used

Answer 13

Proteinaceous plugs of dense, mesh-like mucoprotein +/- cells accumulate in distal portion of nephron Low number (<2/HPF) can be normal Increased number relates to tubular disease Try to identify associated cells, e.g. epithelial, WBC, RBC

Answer 14

pus in your pee Leucocytes Cystocentesis sample - <3/HPF <8/HPF catheter/voided High counts = pyuria +/- bacteria

Answer 15

Most commonly seen in dogs and cats Neutral-alkaline urine UTI’s Diet thin long, pyramidal

Answer 16

Hexagonal Acidic Urine Abnormal finding Inherited defect in proximal renal tubular transport of AA’s Concentrated, acidic urine Radiolucent

Answer 17

Cross-striations, “envelope” Acidic urine Can be seen in clinically normal animals or storage artefact Or urolithiasis, hypercalcuria, hyperoxaluria..

Answer 18

Picket fence Abnormal in cats/dogs Ethylene glycol ingestion Not 100% sensitive Can be seen in normal horse

Answer 19

Alkaline Urine Yellow-brown or colourless Common in equine Not seen in dogs and cats

Answer 20

Orange-reddish brown Low number routinely observed in dogs

Answer 21

Acidic urine Abnormal finding in most breeds Routine finding in Dalmations

Answer 22

Aggregates/no defining shape Urates - acidic Phosphates – alkaline Xanthene

Answer 23

A calculus (stone) in the urinary tract Single or multiple Cystolith, ureterolith, nephrolith… Remember – Crystals do NOT = Urolith Recognised in all species Common urolith types vary with species Calcium carbonate – horses, rabbits Magnesium ammonium sulphate, calcium oxolate – dogs, cats One mineral normally predominates Renomegaly – uni/bilateral +/- pain Renal failure if bilateral “big kidney-little kidney” cats

Answer 24

Kidney stones Asymptomatic Incidental finding on x-rays Associated with pyelonephritis Pain, pyuria, pyrexia

Answer 25

Normal respiration

Answer 26

Increased respiratory rate (not necessarily depth) Primary cardiac disease Neurological disease- Damage to respiratory control centre Pain Stress Hyperthermia- Cooling mechanism Metabolic disease Acidosis/alkalosis Increased PaCO2 Abdominal discomfort Restricted movement of diaphragm Primary respiratory disease

Answer 27

Absence of respiration

Answer 28

Alterations in ventilation at the alveolar level

Answer 29

Increased CO2 in blood Hypoventilation Inc prodn of CO2 Primary drive for respiration

Answer 30

Decreased O2 in blood Poor O2 intake Hypoventilation Increased O2 consumption Decreased O2 carrying capacity

Answer 31

noisy breathing that occurs due to obstructed air flow through a narrowed airway. as compared to stertor, which sounds like a snore, stridor is a high-pitched sound that results from rigid tissue vibrations. It is typically associated with laryngeal or tracheal disease. Laryngeal paralysis and tracheal collapse are two common presentations in companion animal practice.

Answer 32

This term implies a noise created in the nose or the back of the throat. It is typically low-pitched and most closely sounds like nasal congestion you might experience with a cold, or like the sound made with snoring

Answer 33

Causes marked inspiratory effort Dynamic collapse of soft tissues due negative pressure associated with inspiration Inspiratory STRIDOR or STERTOR

Answer 34

Thickening, inflammation and mucus Causes increased expiratory effort Small airways held open during inspiration Early collapse during expiration

Answer 35

Expansion of the thorax restricted Decreased tidal volume Tachypnoea / short-shallow breaths Hypoventilation

Answer 36

Paradoxical movement of the chest wall Trauma – “Flail” chest Terminal respiratory failure – fatigue of muscles

Answer 37

Inc. nasal secretions Allergic rhinitis Acute Inflammation Viral infection

Answer 38

Inc. mucus prodn Chronic disease

Answer 39

Bacterial infection 1o or opportunistic pathogen

Answer 40

Trauma Clotting disorder Vascular disease

Answer 41

Nasal cavity Paranasal sinuses Guttural Pouch (horses)- sometimes bilateral Nasopharyngeal- sometoimes bilateral

Answer 42

URT Origins- Guttural Pouch (horses) Nasopharyngeal Trachea LRT Origins- Bronchoalveolar space Oedema, Pneumonia Pulmonary vasculature Haemorrhage

Answer 43

a disease that affects the upper airway in horses. It causes a decrease in airflow to the lungs and can cause exercise intolerance. Horses with the disease are called “roarers” because they make a characteristic respiratory noise that sounds like “roaring” when exercised Common cause of poor performance in race horses Also occurs in dogs, in association with hypothyroidism

Answer 44

Interstitium is the space between the alveoli and capillaries Interstitium becomes more prominent Air still present in alveoli and normal vessels seen Diffuse (unstructured) - e.g. oedema/ diffuse lymphoma Nodular – e.g. soft tissue mass ie neoplasia/abscess Underexposure, expiration or obesity can look similar – often misdiagnosed

Answer 45

Thickened bronchi Infiltration/mineralisation of bronchial walls or due to peribronchial changes thickning/ mineralisation of the brochial walls or peribrochial changes result in Classical ‘donuts’ or ‘tramlines’ Bronchi may be more obvious in the periphery of the lungs where normally wouldn’t be seen

Answer 46

Consolidation or collapse of alveoli Air in alveoli is replaced by fluid (oedema/haemorrhage) or cells Air bronchogram is commonly seen Can be focal or diffuse Examples; bronchopneumonia, aspiration pneumonia, oedema, haemorrhage, neoplasia, lung lobe collapse or torsion

Answer 47

Any changes to the size, course or opacity of the pulmonary vessels Vessels may be larger or smaller than normal or may be tortuous Commonly seen associated with cardiac disease Tortuous vessels seen with heartworm Differentials depend on vessels affected

Answer 48

Fluid in the pleural space Transudate, exudate, haemorrhage, chyle lung edges to move away from the thoracic wall

Answer 49

Air in the pleural space

Answer 50

Sampling of tracheal mucus Trans-endoscopic Trans-tracheal Representative of tracheal secretions and ascending lower airway secretions Cytology + Culture

Answer 51

Sampling of bronchoalveolar space Trans-endoscopic Blind Cytology on

Answer 52

Neurocardiogenic Cardiogenic

Answer 53

Bradyarrhythmia and vasodilation - Vasovagal- occurs when you faint because your body overreacts to certain triggers, - Tussive- known also as laryngeal vertigo or laryngeal epilepsy, is a. syndrome in which fainting and vertigo with or without convulsions follows. a paroxysm of coughing - Situational- when a patient faints in response to a specific trigger, or a specific situation. Some triggers can include: Swallowing. Coughing. Prolonged periods of straining

Answer 54

Hypotension-inducing arrhythmias - Sinus arrest - V Tach - AV block Combination of structural heart disease & less hypotensive inducing arrhythmias +/- excitement/ exertion Intermittent, profound hypotension resulting in marked reduction in blood flow to brain Estimated blood pressure fall ≤50% Arrhythmia Asystole – sinus arrest or ventricular standstill Marked reduction in cardiac output – rapid V Tach Duration 10-30 seconds Activity level and presence/ absence structural heart disease Pulmonary hypertension Most common cause bradyarrhythmias Might be intermittent

Answer 55

Intermittent, profound hypotension resulting in reduction in blood flow to brain BUT lesser degree of hypotension cf. syncope Arrhythmia Less rapid v tach SVT Less profound bradyarrhythmias Structural heart disease and pulmonary hypertension may exacerbate Excitement/ exertion

Answer 56

Disorder of impulse formation and conduction systems of the heart Dogs <60bpm and cats <100bpm Bradycardias to consider: Advanced AV block (High grade 2nd degree and 3rd degree) Sinus arrest Atrial standstill due to hyperkalaemia Persistent atrial standstill Can be drug induced ACP Opioids Alpha2-agonists B-blockers, calcium channel antagonists and potassium channel blockers are all c/i in sinus bradycardia, SSS and AVB greater than 1st degree Sinus bradycardia usually high vagal tone and does not result in syncope

Answer 57

Supraventricular and ventricular tachycardias Dogs >160bpm and cats >200bpm Supraventricular tachycardia Most common is atrial fibrillation (AF) New onset – weakness, collapse or syncope SVT is an umbrella term AF, accessory pathways, atrial flutter… Regular SVT less common cause of syncope Ventricular tachycardia Boxers and Dobermanns Can drop CO dramatically Sudden death – more so when abnormal function of LV

Answer 58

Blue or grey skin or lips (cyanosis) happens when there's not enough oxygen in your blood,

Answer 59

displays the right ventricular outflow tract which is usually a third of the normal left ventricle.

Answer 60

e define several short-axis views, each cutting the heart at a different level between the base and the apex. The entire heart can be scanned using these short-axis views

Answer 61

FS (%) = (Left ventricular internal diameter during diastole – Left ventricular internal diameter during systole)/ LVDd calculated by measuring the percentage change in left ventricular diameter during systole. It is measured in parasternal long axis view (PLAX) using M-mode. The end-systolic and end-diastolic left ventricular diameters are measured. if there are no abnomalities fractional shortening correlates with ejection fraction- the amount of blood that the heart pumps each time it beats FS% is affected by many external factors therefore has its limitations

Answer 62

Left ventricular internal diameter during diastole cm/Body Weightˆ0.294 For those dogs which are cross breeds are pure bred dogs with no published reference ranges available, then the “Cornell method” scales the LVDd (cm) to bodyweight (kg

Answer 63

Using Echocardiography, the mitral Valve E-Point to Septal Separation (EPSS) is a straightforward approach that roughly corresponds to the status of left ventricular (LV) function, but its use has been limited to echocardiography and without solid quantitative correlation to left ventricular ejection fraction (LVEF) he minimal distance between the anterior leaflet of the mitral valve and the septal endocardium over several cardiac cycles.

Answer 64

Mannheimia haemolytica Pasturella multocida Histophilus somnus Mycoplasma spp. Others

Answer 65

Parasitic bronchitis, commonly known as husk, is caused by lungworm, Dictyocaulus vivaparus, invasion. Unlike most respiratory disease, which tends to be seen in winter months, this disease is only seen from late spring until early autumn. Like other parasitic diseases, its aetiology is dictated by its lifecycle. Once infection occurs by ingestion the infective larvae penetrates the gut wall, migrating through the body to the lung where it reaches adulthood and begins egg laying. The eggs are coughed up, swallowed and pass out through faeces

Answer 66

Trypthophan toxicity respiritory disease in cattle Fog fever is seen rarely in cattle grazing lush pasture. It is due to an excess of tryptophan in the diet which the animal can’t process quickly enough resulting in toxic damage to the lungs.

Answer 67

an allergic reaction to the inhalation of fungal spores usually from mouldy silage

Answer 68

Enzootic calf pneumonia Pneumonic pasteurellosis (shipping fever) Mycoplasma bovis IBR RSV PI3 Verminous pneumonia Fog Fever Farmers lung Aspiration pneumonia Embolic pneumonia (vena caval abcess) ?Stridor - Calf diptheria (Fusobacterium necrophorum) ?Tachypnoea - Septicaemia (eg salmonella Dublin)

Answer 69

Heart disease is any condition affecting the cardiovascular system - chronic in nature e.g. cardiomyopathy - acute in nature e.g. myocarditis - may or may not have clinical signs associated with it e.g. syncope, exercise intolerance - abnormalities on physical examination usually present e.g. heart murmur Heart failure is a syndrome where the heart can no longer meet the metabolic demand of the body - Usually acute onset - Clinical signs present e.g. exercise intolerance, syncope, lethargy, anorexia etc. - Physical examination abnormalities present e.g. fluid thrill, dyspnoea, crackles, jugular pulsation etc.

Answer 70

audible s3 and s4 sounds Normally heard in dogs and cats; Occur during systole S1 ‘lub’ Closure of AV valves S2 ‘dub’ Closure of semilunar valves Not normally heard in dogs and cats Gallop sounds (occur in diastole) S3 Early diastolic filling Not heard in compliant ventricle Systolic dysfunction S4 Atrial contraction Forceful atrial ejection into a noncompliant ventricle Hypertrophic/ restrictive cardiomyopathy

Answer 71

1 – barely audible, need quiet room 2 – audible but quieter than heart sounds 3 – clearly audible and as loud as heart sounds 4 - louder than heart sounds 5 – THRILL (PALPATION) present 6 – Audible with stethoscope lifted off chest Mild/ moderate/ loud/ thrilling (Ljungvall 2014)

Answer 72

Mitral regurgitation- Grade can correlate with severity (MMVD not DCM) Pansystolic worse (MMVD) Can be musical/ whooping Often radiates to right a type of heart valve disease in which the valve between the left heart chambers doesn't close completely, allowing blood to leak backward across the valve. Tricuspid regurgitation- Difficult to distinguish from radiating left sided murmurs Vary with respiration Tricuspid valve dysplasia Pulmonary hypertension Degeneration of valve occurs when the valve's flaps (cusps or leaflets) do not close properly.

Answer 73

Harsh sounding Radiate widely to thoracic inlet Low grade are difficult to distinguish from physiologic/ innocent (Cats – HOCM dynamic) The valve between the lower left heart chamber and the body's main artery (aorta) is narrowed and doesn't open fully. Pulmonic stenosis Left heart base Radiate dorsally he narrowing of the pulmonary valve, which controls the flow of blood from the heart's right ventricle into the pulmonary artery

Answer 74

Innocent- Puppies and kittens No structural heart disease Grade 1-3 Systolic Left heart base Don’t radiate widely Functional- Associated with disease process Anaemia Hyperthyroidism Fever Hypertension Pregnancy No structural heart disease Grade 1-3 Systolic Left heart base Don’t radiate widely

Answer 75

Usually left to right Smaller defect louder murmur Right sternal border Increased right side pressure Quieter Bi-directional Right to left Absent

Answer 76

Murmur not directly related to ASD Only large defects Increased blood flow Relative pulmonic stenosis Left heart base

Answer 77

Respiratory disease – cyanosis, dyspnoea/ tachypnoea, muffled heart sounds, crackles, dull percussion, cough, syncope Neoplasia – ascites, muffled heart sounds, dyspnoea/tachypnoea, dull percussion, weakness Hypoproteinaemia – ascites, muffled heart sounds Neurological disease – paresis, paralysis, weakness, syncope Metabolic disease – syncope, weakness, tachypnoea

Answer 78

Heart murmur (dog vs cats) Arrhythmia (dogs vs cats) Gallop sound Cat with cold hindlimbs Cyanosis Presence of goitre Retinal detachment Some neurological signs

Answer 79

Dyspnoea/ tachypnoea Crackles in lungs Ascites (fluid thrill) Jugular distension Significant jugular pulsation Muffled heart or lung sounds Positive hepatojugular reflux Pulsus alternans/ paradoxus Peripheral oedema Plus usually signs of heart disease

Answer 80

CARDIAC DISEASE- Cardiomegaly causing left mainstem bronchus compression Congestive heart failure (fulminant pulmonary oedema) RESPIRATORY DISEASE Upper airway dz (laryngeal paralysis, BUAS, tracheal collapse) Lower airway dz (infectious/ inflammatory/ neoplastic)

Answer 81

Chronic Myxomatous Mitral Valve Dz/CMVD - Dilated Cardiomyopathy/DCM - Hypertrophic Cardiomyopathy/HCM - Pericardial Effusion/PE - Restrictive Cardiomyopathy/RCM Patent Ductus Arteriosus * Mitral Valve Dysplasia * Tricuspid Valve Dysplasia * Pulmonic Stenosis

Answer 82

horacic rads with echo are the gold standard Echocardiography will also diagnose the underlying disease, provide chamber size (prognosis) and identify any effusions

Answer 83

vertebral heart scale measured on VD and DV radiographs a method for measuring heart size in thoracic radiograph 8.5 – 10.5 in dog 7.5 in cat

Answer 84

diagnostic test for heart failure and its management. It has a very high diagnostic sensitivity for HF Non-cardiac causes of rraised NT-proBN-  Systemic hypertension  Hyperthyroidism  Renal failure

Answer 85

the most commonly used method to evaluate left atrial (LA) size in dogs Normal LA dimension was defined as an LA/Ao ratio <1.6

Answer 86

Diaphragm often appears as 3 ‘humps’ Distance between diaphragm & heart is greater than for DV Better visualisation of accessory lobe Gas should be in the pylorus Right and ventral

Answer 87

Normal width (DV) ○ < 2/3 width of thorax * Normal width (lateral) ○ 2.5 – 3.5 intercostal spaces wide  Significant breed variation * Normal height (lateral – 5th rib) ○ 2/3 height of thorax

Answer 88

Cat - Normal width (DV) < 2/3 width of thorax Normal short axis (lateral) = cranial 5th rib to caudal 7th rib Normal long axis (lateral) 2/3 height of thorax

Answer 89

O’Clock: Aortic Arch = 11-1 Right Atrium = 9-11 Main PA = 1-2 Left aurical = 2-3 Left ventricle = 2-5 Right Ventricle = 5-9

Answer 90

1. Assess technical quality Good technique is essential to obtain diagnostic radiographs Positioning Centring Collimation Exposure factors Labelling Artefacts

Answer 91

A minimum of 2 orthogonal views Beyond that – case dependent! Routine (inc cardiac) cases – RL and DV Screening for metastases RL + LL + VD/DV Specific lung pathology – RL + LL + VD Appearance unclear on one lateral and DV/VD – take the other lateral

Answer 92

Cardiac silhouette position more consistent Diaphragm obstructs less lung field More lung between cardiac silhouette and thoracic wall Position: Right lateral recumbency legs secured cranially, neck extended foam wedge to prevent rotation Lateral view: Centre beam slightly caudal to caudal border of scapula Collimate to thoracic inlet, thoracic spine, sternum and diaphragm (cranial abdomen)

Answer 93

Heart rotates to one side and distorts shadow May produce better pulmonary detail Can see more of the lung fields centring/collimation Ensure symmetrical positioning with spine and sternum superimposed (to avoid axial rotation) Centre beam in midline, at level of caudal border of scapula Collimate to thoracic inlet, diaphragm and body wall (skin edges) – unless investigation requires otherwise.

Answer 94

Safer in dyspnoeic patient Heart lies in anatomically correct position – easier to interpret cardiac silhouette centring/collimation Ensure symmetrical positioning with spine and sternum superimposed (to avoid axial rotation) Centre beam in midline, at level of caudal border of scapula Collimate to thoracic inlet, diaphragm and body wall (skin edges) – unless investigation requires otherwise

Answer 95

Aim to produce a horse ‘sedated enough’ for ketamine induction Healthy horses often receive ACP I/M Associated with improved outcome and better oxygenation Place IV cannula Alpha-2 agonist IV Xylazine shortest acting and can ‘top up’ - ? Good choice with colics Detomidine intermediate action (45 minutes), small volumes Romifidine longest acting (up to 90 minutes) and ? Less ataxia – standing sx? Less common technique – infuse GGE until ‘knuckling’ then induce Centrally acting muscle relaxant Infused immediately prior to induction until horse is ataxic & as part of TIVA often called ‘Triple Drip’ Currently licensed and produced by Dechra Best to use to 5% or 10% solution Can substitute benzodiazepines (BZD) midazolam, diazepam (zolazepam) Used in combination with induction agents to improve relaxation Good in foals alone, don’t use in adults alone

Answer 96

Centrally acting muscle relaxant Infused immediately prior to induction until horse is ataxic & as part of TIVA often called ‘Triple Drip’ Currently licensed and produced by Dechra Best to use to 5% or 10% solution Can substitute benzodiazepines (BZD) midazolam, diazepam (zolazepam) Used in combination with induction agents to improve relaxation Good in foals alone, don’t use in adults alone

Answer 97

Ketamine - Dissociative anaesthetic Excellent anaesthesia combined with other drugs Must not be used alone (seizures) Eyes remain open and central, less cumulative than thiopentone Can be used as ‘top ups’ (don’t exceed induction dose) Takes up to 2 minutes to ‘go down’ Used in combination with acepromazine, alpha 2 agonists, BZDs or guaifenesin (GGE)

Answer 98

Acepromazine im, wait approx 30-45 minutes Detomidine iv, wait 5 minutes, HR>20 bpm, adequate sedation must be apparent Diazepam/ketamine iv for induction (can use ketamine alone) Ketamine iv top ups q 8-15 mins (0.1-0.2mg/kg) OR ‘triple drip’ (GGE, ketamine, alpha-2) Add ¼ dose detomidine after 4/5 doses if using ketamine alone DO NOT leave until horse standing Field recoveries usually smoother than hospital Advice to owner and arrange follow up Flies Bleeding Swelling

Answer 99

Acepromazine im, wait approx 30-45 minutes Detomidine iv, wait 5 minutes, HR>20 bpm, adequate sedation must be apparent Diazepam/ketamine iv for induction (can use ketamine alone) Intubate, maintain on isoflurane in oxygen Monitor depth, keep ABP > 70mmHg, and PCO2 <60mmHg IPPV if necessary. Sedate for recovery

Answer 100

LEGAL ASPECTS – check licenced drugs Many procedures done standing Induction of anaesthesia usually achieved iv (calves can be masked induced) Some cows may drink chloral hydrate...

Answer 101

Can be achieved with drugs given im (deep), iv or via mask with inhalant Ketamine, alfaxalone, propofol Ketamine combinations Malignant hyperthermia (rare condition of pigs will manifest itself soon after exposure to inhalant usually), rapidly fatal, can be treated with dantrolene

Answer 102

Hypotension- Reduce IAA, fluid boluses, pressors/anticholinergics Inadequate anaesthesia and poor recovery- Is usually inadequate analgesia and premedication! Anaesthetic overdose- Use of alpha-2s, adding CRIs and not reducing vaporiser Equipment/monitor issues- Check first! Hypothermia – delayed recovery and arrhythmias Maintain body temp (warming devices) Low glucose Cardiac dysrhythmias- Bradycardia: Alpha-2s, hypothermia, anaesthetic overdose Tachycardia: Nociception, hypovolaemia, drugs

Answer 103

Increased intra-thoracic pressure Gas flow from flowmeters has nowhere to escape Increased intra-thoracic pressure as lungs inflate Increased alveolar pressure causes: Compression (collapse) of pulmonary capillaries (reduced preload) Compression of heart chambers (decreased filling) Compression of aorta (increased afterload) => Dramatic reduction in cardiac output Circulatory arrest  Alveolar damage / rupture

Answer 104

air becoming trapped in tissues beneath the skin. The condition is rare, but it can occur as a result of trauma, injury, infection, or certain medical procedures. Doctors sometimes refer to subcutaneous emphysema as crepitus, tissue emphysema, or subcutaneous air. can result from ruptured trachea caused by et tube

Answer 105

can cause cardiovascular arrest Start CPR Specific treatment for local anaesthetic overdose- Lipid infusion: Intralipid 20% Bolus 1 ml/kg over 1 min Q 3-5mins Total dose 3-4 ml/kg CRI: 0.25 ml/kg/min “until haemodynamic recovery” Initial research in dogs Expt overdose of bupivacaine 10 mg/kg i/v Cardiac massage unsuccessful for 10 mins 6/6 lipid treated dogs survived; 0/6 untreated dogs survived Normal sinus rhythm returned w/in 5 mins of lipid infusion

Answer 106

Older/sick patients Multiple underlying conditions Cardiovascular depression Vasoactive drugs (which?), inhaled anaesthetic agents (effects?) Hypothermia Fluid loss Overstimulation Nociception

Answer 107

What is the rate What is the overall rhythm Is there a P for every QRS Is there a QRS for every P Are there aberrant (usually ventricular) complexes What do the monitors tell you about the patient?

Answer 108

seen as longer streaches between each PQRST complex Perfectly normal rhythm Often seen in fit anaesthetised patients Sign of high vagal tone Be careful of procedures that stimulate vagus such as ocular surgery

Answer 109

multiple p waves without a PQRS complex Can be caused by vagal stimulation or very ‘deep’ anaesthesia Can be idiopathic Commonly as a result of alpha-2 agonists Very rarely HIGH dose opioids Treatment? If necessary, antagonise the alpha-2 agonist (or administer naloxone?) Decrease anaesthetic depth If still no response and reduced cardiac output? Consider atropine/glycopyrrolate

Answer 110

very strange p waves very deep s waves large t waves Treatment – Stop further deterioration, ensure all other parameters are normal

Answer 111

ocational very deep s waves coupled with large t waves Stop further deterioration, ensure all other parameters are normal Recover asap, ?amiodarone Then cardiology Rate control if there is underlying heart disease – medical mx Electrical DC cardioversion may be an option

Answer 112

occasional very large qrs waves with pause after Check physiology – often due to hypoxia or hypercapnia. Sometimes low blood pressure Add analgesia – may be due to nociception Possible lidocaine if becoming frequent

Answer 113

very squshed look of whole line no visibel p waves with frequent qrs complexes and strange t waves Causes? Anything that causes tachycardia! Nociception, hypotension, hypercapnia, hypoxia, hypokalaemia, drugs – which? Treatment? Underlying cause Lidocaine/magnesium/amiodarone

Answer 114

small pqr very deep s wave and large t wave Often a deterioration of SVT – treat underlying cause Often as a result of sepsis or a major underlying condition May deteriorate into ventricular fibrillation (often fatal) Treatment = underlying cause, lidocaine, amiodarone, magnesium Ensure all other parameters normal

Answer 115

qrs without p wave with large qrs complex Would you treat this? Possible due to alpha-2 agonists or high dose opioids? What would you do? Treat cause otherwise ensure all other physiology is normal

Answer 116

upperlip, roof of nose, skin rostral to canal Transbuccal Transdermal Place needle into canal

Answer 117

maxilla, upper teeth, nose, upper lip Transorbital approach Transdermal approach Ventral to notch in zygomatic arch Transmucosal – cannula into infra-orbital canal

Answer 118

akinesia of globe, desens, eye and orbit Auriculopalpebral Supraorbital 3 point Petersen block Retrobulbar

Answer 119

lower lip, insisors Mandibular nn Mental foramen

Answer 120

mandible, teeth,skin mucosa Medial mandible Just rostqral to angular process Or transmucosal – medial aspect mandible

Answer 121

Displays percentage oxygen saturation of haemoglobin Accuracy is affected by poor circulation (common in critical patients) ambient light movement of the probe chow-chows Useful post-op saturating on room air? Limitations- High/low heart rates Probe design How is the haemoglobin saturation SPO2% (reading from pulse oximeter) related to PaO2 (partial pressure of oxygen in the blood)? Oxygen content is dependent on both SaO2 and PaO2 Oxygen content = (1.39 x Hb x SPO2%) + (0.003 x PaO2) Hb of 15g/dL (PCV 45%) Cyanosis may start to manifest at SpO285% - no other signs Haemoglobin of 9 g/dL (PCV 27%) The threshold SaO2 level for cyanosis is lowered to about 73% (PaO2 38 mm Hg), the patient would certainly have other signs Remember, >95% saturation tells us nothing about blood oxygen content- could be anamic

Answer 122

Capnography (carbon dioxide measurement) conveys information relating to both respiratory and cardiac function The end tidal carbon dioxide concentration is measured from the alveolar plateau and should remain constant with unchanged ventilation and cardiac output Main-stream and side-stream machines are available Normal ET CO2 = 35–45 mm Hg Hyperventilation – Decreased ETCO2 Hypoventilation - Increased ETCO2 Cardiovascular status CVS depression / arrest Reduced delivery CO2 to lungs can also show airway obstruction and rebreathing Other indicators Oesophageal intubation Leak at cuff/Patient disconnection Adequacy of resuscitation

Answer 123

The alveolar concentration (at 1 atm) producing immobility in 50% of patients in response to a noxious stimulus i.e. Potency MAC is for healthy, un-premedicated patients MAC affected by Age, N2O, hypotension, hypoxia, anaemia, opioids, sedatives, LAs, pregnancy MAC not affected by Stimulation, duration, species, sex, CO2, NSAIDs Isoflurane 1.28 (dog) 1.63 (cat) Halothane 0.87 (dog) 1.14 (cat) Sevoflurane 2.2 (dog) 2.58 (cat) Desflurane 10.3 (dog) 9.8 (cat) Nitrous oxide 188-297 (dog) 255 (cat)

Answer 124

total intravenous anaesthesia Can be used for short procedures in small animals/aggressive patients E.g. ‘quad’ anaesthesia for cat neuters Routinely used for field procedures in horses E.g. ‘GGE, ketamine, alpha-2 agonist – so called triple drip Various ‘recipes’ GGE (Guaifenesin, a centrally acting skeletal muscle relaxant with little or no analgesic properties) Supplied as 5% guaifenesin in 5% dextrose and infused to effect until signs of ataxia are seen, at which time IV bolus of ketamine is given Maintained with infusion given to effect

Answer 125

partial intravenous anaesthesia Goals of PIVA Reduce MAC Reduce cardiopulmonary depression Provide additional analgesia Improve environmental impact ideal drugs- MAC reduction Analgesic Minimal toxicity Minimal effects on the body Short context sensitive half life Compatible with other drugs NO single drug meets these requirements Hence the need for combinations

Answer 126

Seen in sheep continuously exposed to wet pasture – often lambs but can be seen in housed ewes when straw becomes wet and warm Fusebacterium Necrophorum – can be zoonotic – human wounds have been swabbed and F. Necrophorum found – wear gloves when examining lame sheep! Mild and transient lameness, rapidly resolves with treatment Dermatitis involving some or all of the skin between the claws of the feet – skin between claws appears red and inflamed with white discharge V common, less important than footrot/CODD, but associated with pathogenesis of foot abscesses and foot rot

Answer 127

Footrot – 90% of lameness in the national flock Dichelobacter Nodusus (Bacteroides) BUT needs F. necorphorum to facilitate epidermal invasion D.nodosus – obligate parasite, can’t survive in the environment for more than 1 week Also requires devitalised skin – chronic exposure to wet conditions and faecal contamination Fly strike can occur in affected feet Characterised by lameness which can be severe, often recumbent leading to reduced feeding time, weight loss, poor wool quality Very effective vaccine against footrot. Acts as treatment and prevention. Timing is important A second injection can be needed 4-6 weeks One injection will last 6 months. Diagnosis is essential

Answer 128

Contagious Ovine Digital Dermatitis Relatively ‘new’ disease – ongoing research Bacteria – treponeme species. Some association with cattle with Bovine Digital Dermatitis Link between CODD and footrot Usually SEVERE lameness with one claw of one foot affected Initially ulcers develop on the coronary band which then under-run the hoof, can lead to whole hoof avulsion Graded 1-5 Can lead to permanent hoof growth problems Often needs systemic treatment with antibiotic and NSAIDs

Answer 129

Often individual rather than ‘whole flock’ issue Unknown aetiology – walking on stony ground, nutritional imbalance? ‘Shelley Hoof’ Separation of the hoof wall from the underlying tissues Lameness caused by dirt packing into space created Can lead to abscess formation

Answer 130

Painful red swellings caused by: Over-trimming Chronic untreated lesions Chemical irritation

Answer 131

viral disease usually seen around mouth of ewes/lambs – causes proliferative lesions around coronary band

Answer 132

– ongoing research into aetiology – can appear similar to orf lesions

Answer 133

lame in all 4 feet, often after grain gorging or over-fat rams, can lead to longer term hoof deformation Broken leg bottom left

Answer 134

spinal abscess as a result of any systemic bacterial infection can initially present as lameness before progressing to ataxia

Answer 135

Most common = septic arthritis ‘Joint-ill; Streptococcus Dysgalactiae Transmission still unknown – cord/tagging/tailing/castrating/oral/vaginal canal? Swollen joints, ill thrift, death 1-2% of flocks, can be up to 50% of lambs in severe outbreaks control- Lamb outdoors!- Reduces bacterial load for newborn lambs Wear long gloves for each assisted lambing Maintain clean dry lambing shed and pens Consider if tailing/castration necessary for the particular system Check colostrum intake Research evidence suggests that wearing long disposable gloves for lambing will be the most effective method to reduce the prevalence within a flock

Answer 136

Disruption to horn growth due to pressure on the corium underneath P3 Risk Factors: Standing time Surfaces Foot trimming Fat mobilisation Inflammation Remove pressure Block Trim loose horn NSAID Prevention: Cow comfort – minimise standing times Maximise transition health Ensure cows aren’t lame in dry yards Prompt ID and treatment Foot trimming technique and strategy

Answer 137

Multifactorial Strong bacterial component Treponeme spp Genetic susceptibility Hoof hygiene!

Answer 138

Bacterial infection of interdigital tissue F. Necrophorum et al Painful, swollen ID space Characteristic fragrance Treatment Systemic antimicrobials NSAID Local treatments Prevention Similar to DD Minimise risk of interdigital trauma

Answer 139

Prevention: Hygiene and trimming of loose heel horn v shaped lesions

Answer 140

3-4x/week Not too strong/acidic (below pH3) No more than 200 cows Effective design required Commonest ingredients – formalin, CuSO4

Answer 141

using oxygen to wash out the nitrogen contained in lungs after breathing room air, resulting in a larger alveolar oxygen reservoir. With any rebreathing system where carrier gas is oxygen Use higher flows for ~10 minutes Risk of alveolar hypoxia N.B also after short disconnections – movement between theatres etc

Answer 142

High gas flow requirements Loss of heat and moisture Cheap to purchase, expensive to run Low resistance to respiration Suitable for very small patients Rebreathing circuits use a carbon dioxide absorber to trap and remove CO2 so the patient can breathe gases that have been recycled through the machine. Non-rebreathing circuits use high gas flows to washout expired CO2 from the circuit before the patient takes its next breath. t piece bain lack mcgill

Answer 143

Based on multiples of minute volume, where minute volume is; Respiratory rate x Tidal volume OR 200 ml per kg

Answer 144

non-rebreathing Reservoir bag at fresh gas inlet Awkward to use circute factor of 1 1 x Vm (Vm = Vt x RR) or (Vm =200ml/kg) resivour bag is attached to one limbs >5kg not sutible fopr ippv

Answer 145

Co-axial Magill circut factor is 1 1 x minute volume (tvxrr) Damage to inner limb results in rebreathing resivour bag is attached to two limbs >10 to <25-30kg not sutible for ippv

Answer 146

Alternative to T-piece for patients under 10 kg Bodyweight range 1-10kg 1 x minute volume No bag twist hazard Very low resistance Easy to clean smooth bore tubing

Answer 147

Suitable for very small patients, < 8 kg 2-3 x Vm circute factor is 2-3 Suitable for IPPV resouvouir back further from gass inlet than lack, attached to one limb, with another limb coming form gass outlet

Answer 148

Co-axial T-piece Suitable for 7 – 10 kg circute factor of 2-3 2- 3 X Vm Beware – damage to inner tube like magil but with inner tube

Answer 149

versitile circle unit has sodalime can be converted form circle to lack to t- piece lever upright (lack) - lever down (T-piece) - circle Versatile, suitable for 4 kg - >20 kg Pros Compact Well designed Scavenge at machine end Straightforward conversion to IPPV (Nb increase flow) Applies PEEP Increases FRC Prevents microatalectasis Lowers work of breathing in human infants Cons Cost Very heavy – strain on common gas outlet Flows of 50ml/kg/min in lever up (lack) not substantiated in animals Relies on 3 human references

Answer 150

Inspect system Connect to common gas outlet Test system for leaks Check unidirectional valves on circle Specific tests to check integrity of co-axial lack and co-axial Bain

Answer 151

Pneumatic Medullary

Answer 152

Ventral tail vein Care with species that perform autotomy Jugular vein Can be considered for leopard geckos

Answer 153

Ventral tail vein Recommended site Care not to insert needle into hemipenes or cloacal musk glands Cardiocentesis CARE  risks of laceration to ventricle and risk of pericardial haemorrhage

Answer 154

Venepuncture sites Right jugular vein Can obtain large volumes Gentle pressure to achieve haemostasis Basilic (ulnar/brachial vein) Extend wing and visualise vein Vein runs over the elbow area Care as haematoma formation is common Medial metatarsal vein Vein is very short in psittacines

Answer 155

back bar- Horizontal part of the anaesthetic machine circuit between the rotameter block and the common gas outlet Vaporisers are mounted on the back bar, enabling volatile agents to be added to the fresh gases. The pressure in the back bar is approximately 1 kPa at the outlet end, and may be 7–10 kPa at the rotameter end Contains a ‘blow off’ or pressure relief valve at the outlet end plus safety features to only allow one vaporiser in use Oxygen failure warning device If fitted (Ritchie whistle or electronic) Vaporiser- Expensive and need servicing See maintenance lecture Common gas outlet- Anaesthetic mixture attaches to breathing system Non-return valve Oxygen flush - Bypass vaporiser 35l/min CARE with breathing system valves – expiratory = open

Answer 156

uses a mechanical respirator to deliver a controlled pressure of a gas to assist in ventilation or expansion of the lungs, thereby providing an increased tidal volume for patients with a variety of pulmonary conditions. Intermittent manual – ‘sighing’. A good habit! Close valve + short inspiration up to 20cm water. Chest supra-maximal. OPEN VALVE AGAIN. Continuous manual. Repeated sighing. Can be tiring. Will allow breathing control but turn down vaporiser. Mechanical. Ventilator. TV – 10-20ml/kg. Use large TV with slow rates. Various types. Frees anaesthetist and regular rhythm.

Answer 157

Visual check Leak test; If pop-off valve, close and inflate with thumb over end until no balloon creases Bain – occlude end with syringe with oxygen at 2l/min – flow should drop With no IAA – BREATH into circle to check valves (or use 2 bag method)

Answer 158

used to absorb carbon dioxide USA – baralime. 90% = calcium hydroxide; Ca(OH)2 +CO2 -> CaCO3 + H2O + Heat. Therefore gas warmed and humidified. Colour change – usually to purple but NOT permanent so change if needed at end of anaesthetic. Dust. Tracking of gas. Dead space. Resistance. Hyperthermia. Exhaustion – colour change, no heat, increased heart/resp rate and bp, wound ooze, red mms.

Answer 159

Recommended in adult dogs/cats 3-6 hours, water until premed <3 = food present. >6 = stomach pH drops so reflux is damaging Neonates = from 0.5 to 3 hours – monitor glucose Horses withdraw concentrate overnight (gas distension) – controversial Ruminants withdraw 6 hours and reduce concentrates 12-24 hours Small exotics/furries – shorter times depending on species

Answer 160

Various types available Most are cuffed with a visible pilot balloon Inflate to ~25mmHg – use manometer if possible Murphy, Magill or Cole Use of laryngoscope advisable Flow = ∆𝑃𝜋𝑟4/8∩𝐿 Go as large as possible What size shall I place? Selection based on nasal septal width = 21% accurate Selection based on tracheal palpation = 46% accurate Best technique = visualise larynx using laryngoscope Spray lidocaine (cats, why not dogs?) and WAIT Try largest but have a range available Cut to length – minimise dead space Not possible with armoured tubes Red rubber in common use Crack over time + non-repairable Prone to kinking Irritant Not possible to visualise blockages Low volume high pressure cuff Can lead to tracheal trauma but good seal Difficult to recommend More popular Disposable but reused, silicone tubes repairable Less prone to kinking compared to rubber Non-irritant Allows visualisation of blockages Usually high volume low pressure cuff Less risk of tracheal trauma but relatively good seal

Answer 161

Designed for emergency use in paediatric anaesthesia The shoulder of the tube should impact in the larynx to provide a gas-tight seal However movement or IPPV tends to dislodge the tube Still quite useful for exotic animal anaesthesia

Answer 162

veterinary specific (rabbits and cats) 2 species where ETT placement can be challenging Designed to anatomical standards

Answer 163

High pressure/low volume (red rubber and some silicone ETT) exert pressure on a small part of the tracheal mucosa. May see tracheitis or pressure necrosis This can lead to tracheal strictures Extreme cases may see tracheal rupture Post-op subcutaneous emphysema in cats – but still recommended to use a cuff ALWAYS disconnect from breathing system when changing position whenever a change in recumbency is needed Especially with dental cases where head and neck movement is common Always inflate carefully preferably with manometer Or listen for leaks

Answer 164

Sedation and anxiolysis facilitating handling of the animal Reduction of the stress for the animal Reduction the amount of other anaesthetic agents Provision of a balanced anaesthesia technique Provision of analgesia Counter the effects of other anaesthetic agents to be administered during the anaesthesia procedure e.g. atropine to prevent an opioid mediated bradycardia Contribute to a smooth, quiet recovery after anaesthesia

Answer 165

Potent sedative and analgesic drugs Xylazine was the first 2 agonist to be used in veterinary practice Superseded by medetomidine & dexmedetomidine (cats & dogs), both lasting about 45 minutes Xylazine (30minutes), detomidine (45 minutes)and romifidine (60 minutes, less ataxia) used in horses Xylazine and detomidine used in cattle The superior selectivity of dexmedetomidine makes it the theoretical 2 agonist of choice for use in small animals can be injectable or oral gel Sedation is profound & dose related Alpha 2 agonists provide good analgesia through an agonist effect at spinal cord 2 receptors The duration of analgesia provided by a 10 µg/kg dose of dexmedetomidine is approximately 1 hour Intra-op analgesia improved The dose of induction and maintenance agents required after alpha 2 agonists are dramatically reduced in small animals Intravenous induction agents must be given slowly and to effect (vein to brain circulation time is slowed) Alpha 2 agonists produces a biphasic effect on blood pressure (initial increase followed by a return to normal or slightly below normal values) Heart rate is decreased throughout the period of 2 agonist administration HR 45-60bpm dogs and 100-120 bpm cats Alpha2agonists cause a reduction in cardiac output & in healthy animals. Urine production is increased due to a reduction in vasopressin and renin secretion Endogenous insulin secretion is reduced leading to a transient hyperglycaemia Both liver blood flow and the rate of metabolism of other drugs by the liver are reduced Peripheral vasoconstriction tends to reduce peripheral heat loss As a consequence it can be easier to maintain normothermia during the peri-operative period compared to animals given acepromazine Small ruminants are quite sensitive to alpha 2 agonists #reversable- atipamezole

Answer 166

Alpha 2 sedation and analgesia is rapidly antagonised by the administration of atipamezole, a specific alpha2 adrenergic receptor antagonist Reversal is advantageous because the recovery period is noted to be a high risk time for anaesthetic complications IM atipamezole produces smooth and good quality recoveries IV atipamezole produces a very rapid, excitable recovery from anaesthesia and this route of administration is not recommended It is important to ensure that analgesia is supplemented with different classes of drugs Atipamazole rarely used in horses and cattle

Answer 167

Acepromazine commonest/only licensed one Sedation and anxiolysis that is initially dose dependent With larger doses the duration of action is more prolonged The quality and reliability of sedation can be improved by combination with an opioid (neuroleptanalgesia) Addition of an opioid also provides analgesia, advantageous since acepromazine itself is not analgesic To maximise sedation the animal should be left undisturbed for 30-40 minutes after administration Less reliable sedation cf dexmedetomidine Acepromazine (ACP) is an antagonist of 1 adrenoreceptors and can cause peripheral vasodilation and a fall in arterial blood pressure Avoid in animals with marked cvs disease or animals in shock Acepromazine is long lasting & non-reversible so avoid in hypotensive animals Acepromazine has anti-arrhythmic properties which may be advantageous during anaesthesia Reduction in body temperature occurs due to a resetting of thermoregulatory mechanisms combined with increased heat loss due to peripheral vasodilation No evidence to suggest that acepromazine alters seizure threshold Giant breeds of dog may be “more sensitive” to the effects of acepromazine Some boxer dogs are sensitive to even small doses of acepromazine, which has been attributed to acepromazine induced orthostatic hypotension or vasovagal syncope in this breed Although acepromazine is not contraindicated in boxers, it is not the premedicant of choice in this breed - a very low dose (≤0.01 mg/kg) is recommended and animals should be monitored carefully after administration Acepromazine is a dopamine antagonist Anti-emetic Contraindicated in breeding stallions Acepromazine gel (horses) & tablets

Answer 168

Midazolam or diazepam (MA coming for midazolam, diazepam has MA in France) Benzodiazepines alone produce minimal or no sedation in healthy cats and dogs May even cause excitation due to loss of learned “inhibitory” behaviour Benzodiazepines are therefore given in combination with other sedatives In dogs benzodiazepines often combined with opioids because both classes of drugs are cardiovascularly stable and the combination can provide reliable sedation In cats benzodiazepine and opioid is not very sedative, so benzodiazepine is most commonly combined with ketamine These drugs have minor effects on cardiorespiratory systems Therefore these drugs tend to be used as premedicants in animals with cardiovascular compromise. Benzodiazepines are commonly used to manage convulsions, particularly as a first line intervention for animals presenting in status epilepticus

Answer 169

Acepromazine + opioid Alpha 2 agonist + opioid Alpha 2 agonist + BZD Alpha 2 agonist + Ketamine BZD + Ketamine Opioid + BZD Alpha 2 agonist + BZD + opioid How to choose.... Reason for anaesthesia or sedation Duration of sedation required Procedure to be carried out Degree of pain expected from the procedure Species and breed of the patient Age of the patient ASA classification of the patient

Answer 170

Injectable Induction Agent Quick recovery with no hangover Apnoea if given too quickly Most commonly used anaesthetic in UK (dogs and cats) Alkyl phenol, white emulsion 10mg/ml Soyabean oil, glycerol, egg lecithin, no preservative, NaOH (changes pH) Supports bacteria and endotoxin Use within 24 hours A multi-dose vial with preservative was available (‘Propoflo Plus’ – Zoetis) 28d shelf Rapid onset of action -rapid uptake by CNS Short period of unconsciousness (5-8 mins) Large volume of distribution (lipophilic) Rapid smooth emergence due to redistribution & efficient metabolism (hepatic and extra hepatic) metabolites inactive Respiratory depression (apnoea) - IPPV - Speed of injection? Cardiovascular depression Rapid and smooth recovery Suitable for top ups or TIVA Muscle relaxation usually ok Anticonvulsant ?? Not irritant, pain reported Analgesia ?? probably not ↓ ICP (patients with raised and normal ICP) Rigidity, twitching Apnoea Profound bradycardia Care in hypoproteinaemia Heinz body anaemia in cats ??? Use for patients with pancreatitis / hyperlipoproteinaemia or diabetic hyperlipidaemia Pain on injection ? Local reaction (clear formulation, discontinued)

Answer 171

Injectable Induction Agent Predictable Single use vials Apnoea Rough recoveries

Answer 172

Injectable Induction Agent IM or IV Long recovery? Can be rough recovery Controlled drug

Answer 173

Ultra short acting However difficult (impossible) to source Use currently in horses to ‘top up’ Prolonged recovery in sighthounds - metabolism and body fat Massive skin sloughing if injected extra-vascularly

Answer 174

Steroid Anaesthetics – ‘Saffan’ – no longer available in UK in this form Alphaxalone(6mg/ml)/alphadolone(3mg/ml) Alphaxalone more potent Solubilised by Cremaphor EL Didn’t give it to dogs Used in ruminants & pigs Formulation without Cremaphor (instead a 2-hydroxypropyl-beta-cyclodextrin (HPBCD)) Alfaxan  (Alfaxalone) Is suitable for cats and dogs (& other spp) Alfaxalone is a clear colourless neuroactive steroid Causes anaesthesia by activating the GABA (inhibitory) receptor Alfaxalone has a short plasma elimination half life and is cleared from the body relatively quickly Alfaxalone can be give as repeated boluses or as TIVA to maintain anaesthesia Premedication is preferable Anaesthesia induction is smooth, and the injection is given slowly over 60 seconds. Occasional apnoea is seen and IPPV may be necessary (more than propofol) The drug has good cardiovascular stability, causes no histamine release and produces good muscle relaxation Animals should not be disturbed during recovery as excitement can occur

Answer 175

Ketamine (also Tiletamine in Europe/USA) Weak organic base pH 3.5 Racemic 10% solution (100mg/ml) IV, IM, SC, IP, PO, epidural Dissociative state Used in many species for induction and analgesia Dissociative anaesthesia = detached from surroundings Patient may have their eyes open and make reflex movements during surgery In recovery the patient may be agitated Hallucinations are associated with human ketamine anaesthesia Can be reduced by premedication with benzodiazepines Ketamine increases the intracranial pressure Can be combined with BZD, alpha 2 agonists, acepromazine, opioids Versatile induction agent and wide safety margin Invariably needs to be combined with something Rapid induction Respiratory effects are mixed – bronchodilation and RR usually preserved but my stop! GOOD ANALGESIA CVS effects depend on dose Muscle tone ↑ and jerky movements Salivation and lacrimation ↑ Ketamine can be diluted with sterile water or physiological saline Stormy recovery if disturbed or not adequately premedicated Depth assessment is different (eyes open) Corneal drying - use ‘Lacrilube’ or similar tears Vomiting common with alpha 2 combinations avoid in patients with GI obstruction Avoid in patients with ↑ ICP, ocular surgery, fever, hyperthyroidism Schedule 2 CD

Answer 176

Smooth muscle spasm- Inflammation Colitis / Ulceration- Distension Impaction Gas accumulation- Obstruction Impaction Tension on the mesentery- Displacement Tissue congestion/infarction/necrosis- Torsion/volvulus Strangulation

Answer 177

Mild signs – Restless, Pawing, Flank watching Gas build up / inflammation of GIT / Smooth muscle spasms Moderate signs - Lying down flat out, groaning- Impaction or other simple obstruction Very fractious, violent rolling- Acute, severe strangulation Dull, unresponsive- End-stage – Severe illness due to colic Inappetence Reduced faecal output Vocalising/grunting Agitation Pawing at the ground Lip curling Flank Watching Lying down For long periods Repeatedly Stretching to urinate Rolling / Thrashing Sweating excessively Straining

Answer 178

Any non-gastrointestinal source of abdominal pain Liver disease / hepatomegaly Urinary disease- Renal pain Bladder Dz (urolithiasis) Peritonitis Intra-abdominal abscess Intra-abdominal neoplasia Reproductive disorders Other Non-abdominal, pain mistaken for colic Oesophageal obstruction Rhabdomyolosis (tying-up) Laminitis Pleuroneumonia

Answer 179

Auscultation - GIT borborygmi of the ascending colon (caecum & LC) Auscultation of GIT has some degree of specificity but low degree of sensitivity. Hypermotility: Increased smooth muscle activity - ‘spasm’ colic Local hypomotility: Localised stasis of GIT General absence: GIT ileus – common finding in most colics Very useful for monitoring cases – e.g. progressive loss of motility

Answer 180

Nasogastric reflux Fluid/ingesta reflux from the stomach >2 Litres of fluid is abnormal Usually indicative of small intestinal obstruction (physical or functional) Can occur due to LC displacement (pressure on duodenum) Presence of gastric reflux has significant diagnostic value Majority of cases with reflux need referring to hospital Relieving reflux is also very therapeutic >8L will stretch stomach and be a significant source of pain

Answer 181

ventral band of cecum great vessels caudal pole of left kidney caudodorsal aspect of spleen nephrosplenic space and ligament fecal balls in small colon inguanal rings in stallion bladder when distended Abnormalities: - Impaction - Distension (Gas accumulation) - Displacement - Masses

Answer 182

Assess for presence of changes in peritoneal fluid Serosanguineous colour change/ Increased protein concentration- Serosal compromise – leakage of blood components Increased Lactate concentration- Anaerobic tissue metabolism Presence of ingesta- Rupture of GIT tract High WBC count- Peritonitis

Answer 183

Analgesia Imperative to provide some form of analgesia to a colic case NSAIDs The most common form of analgesics used to treat colic Slow onset and long duration of activity Flunixin meglumine (Finadyne Solution) 1.1 mg/kg iv Potent visceral analgesic Can masks deterioration in CVS status Ketaprofen (Ketofen) 1.1 - 2.2mg/kg iv Phenylbutazone (Equipalazone Injection) 4.4mg/kg iv Alpha-2 agonists- Potent analgesics with rapid onset and short duration of action Allow rapid re-assessment of case progression Xylazine (Rompun, Virbaxyl) Dose rate: 0.2-1.1mg/ml Analgesia for 15-20min Detomidine (Domosedan) Dose rate: 0.01-0.02mg/kg Analgesia for 1-2 hours Romifidine (Sedivet) Dose rate: 0.04-0.08mg/kg Analgesia for 1-3 hours Opiods- Not first line analgesic Usually reserved for higher degree of pain Butorphanol (Torbugesic) 0.05-0.075mg/kg iv Potent analgesic; 1 hour duration Spasmolytics (Anticholinergics) N-Butylscopolamine (Buscopan Injectable ) Smooth muscle relaxant Rapid onset and short duration of activity Good for; Treating hypermotile/spasm type colic ‘Gas’ colic Relaxing rectum prior to rectal examination General Rules For first-line treatment, or where diagnosis is uncertain, use short acting analgesic agents Assessing progression, rapid recurrence of pain or deteriorating CV status is vital in the decision to refer Beware the potent anti-inflammatory effects of flunixin, which can significantly ‘mask’ the early signs of endotoxaemia. Only administer NSAIDs after the diagnosis or CV status have been established

Answer 184

Enteric fluids- Indicated in the vast majority of colic cases Most cases will have a degree of dehydration Contraindicated if NG reflux is present, or suspect small intestinal lesion Excellent way to rehydrate the colonic content (impactions) Bolus(es) of isotonic fluids (tap water + NaCl + KCl) 5-8L can be given q2hrs Purgatives Liquid Paraffin; Magnesium Sulphate (Epsom Salts)

Answer 185

Essentially, any indicators that the case won’t resolve with simple conservative therapy (analgesics & enteric fluids) Non-response to analgesia Significant CV compromise Rapid deterioration despite therapy Complex abnormalities on rectal exam Presence of NG reflux Recurrent/chronic cases with unclear Dx 82.9% survival rate for 1st opinion cases

Answer 186

A loading dose is an initial higher dose of a drug that may be given at the beginning of a course of treatment before dropping down to a lower maintenance dose A loading dose is most useful for drugs that are eliminated from the body relatively slowly, i.e. have a long systemic half-life Without an initial higher dose, it would take a long time for the concentration of these drugs to reach therapeutic levels Examples include ketamine and fentanyl

Answer 187

Effect of drug on the body Drugs are chemicals and as such interact chemically with biological/cellular molecules – most often proteins Enzymes (e.g. ACE inhibitors, aspirin, neostigmine) Carrier Molecules (e.g. flavonoid – Pgp antagonist, digoxin) Ion channels (e.g. verapamil - L-type calcium channel antagonist) Receptors (e.g. benzodiazepine – GABA receptor agonist, adrenoceptor agonists and antagonists ) Structural proteins (e.g. Taxol – Tubulin “agonist”) DNA (e.g. anti cancer agents like Doxorubicin)

Answer 188

the theory of anaesthetic action which proposes that the potency of an anaesthetic agent is related to its lipid solubility. Potency is described by the minimum alveolar concentration (MAC) of an agent and lipid solubility by the oil:gas solubility coefficient.

Answer 189

a compound naturally produced by the body which binds to and activates that receptor. For example, the primary endogenous agonist for serotonin receptors is serotonin, and the primary endogenous agonist for dopamine receptors is dopamine.

Answer 190

the maximum therapeutic response that a drug can produce (example: morphine vs buprenorphine)

Answer 191

Drug Target Interaction If the activation is 100%, namely each time a drug interacts with its target there is a response then the agonist is said to be a “full agonist” If the activation is <100%, the agonist is said “partial agonist”. Partial agonists have lower efficacy than full agonists – even with maximal occupancy of receptors. An agonist has affinity and efficacy – therefore elicits a biological response Agonist: molecule/drug that binds and activates the receptor Affinity: the tendency of a drug to bind to the receptor Efficacy: the tendency of a drug to activate the receptor once bound

Answer 192

the tendency of a drug to bind to the receptor

Answer 193

the tendency of a drug to activate the receptor once bound

Answer 194

Drug Target Interaction Antagonist: molecule/drug that binds a receptor without activation Antagonist have affinity but zero efficacy (as they block the target activity) Main types of antagonism: * Competitive * Non-competitive * Irreversible

Answer 195

Competitive agonists compete with agonists for the receptor binding site. The chemical structure of the agonist and competitive antagonist are often similar (lock and key hypothesis). Antagonist binds to receptor in such a way as to prevent agonist binding Competitive antagonism is surmountable – additional agonist can overcome the receptor blockade. Addition of a competitive antagonist shifts the dose response curve of the agonist to the right (e.g. methadone/naloxone)

Answer 196

Non-competitive antagonists either bind to a different receptor site OR Block the chain of events “post” binding - acting “downstream” of the receptor. shift the efficacy of the agonist down

Answer 197

Antagonist dissociates from the receptor only very slowly or not at all. The antagonist forms covalent bonds with the receptor. Irreversible antagonism is insurmountable – additional agonist cannot overcome the receptor blockade. Often used in drug discovery, rarely in practice – why? BUT……Some irreversible enzyme inhibitors are used in practice – e.g. aspirin, omeprazole

Answer 198

Inverse agonist: drug that reduces the activation of a receptor with constitutive activity (example: GABAA receptor) Can be regarded as drugs with negative efficacy.

Answer 199

Effective concentration. The dose required for an individual to experience 50% of the maximal effect.

Answer 200

Effective dose. The dose for 50% of the population to obtain the therapeutic effect.

Answer 201

toxic dose (or LD50) ÷ effective dose (or ED50) Large TI is safer!

Answer 202

Ion channel cell surface transmembrane receptor Ligand regulated enzyme E.g. insulin receptor G-protein coupled receptors Protein synthesis regulating receptor

Answer 203

(“rapid protection”). Reduction in drug tolerance which develops after a short period of repeated dosing. Not common. Often due to a lack of a co-factor

Answer 204

When a drug becomes antagonistic to its own effects

Answer 205

Change in receptors become resistant to drug stimulation/conformational changes Loss of receptors endocytosis Exhaustion of mediators degradation/low re-expression level Increased metabolic degradation higher concentration of drugs are needed Physiological adaptation crosstalk between body systems, one takes over Drug transporters drug removed from receptor sites

Answer 206

The Veterinary Medicines Directorate (VMD), which is an executive agency, sponsored by the Department for Environment, Food & Rural Affairs VMD is responsible for; monitoring and taking action on reports of adverse events from veterinary medicines testing for residues of veterinary medicines or illegal substances in animals and animal products assessing applications for and authorising companies to sell veterinary medicines controlling how veterinary medicines are made and distributed advising government ministers on developing veterinary medicines policy and putting it into action making, updating and enforcing UK legislation on veterinary medicines

Answer 207

Prescription-only Medicine – Veterinarian must be prescribed by a veterinary surgeon, who must first carry out a clinical assessment of the animal under his or her care.

Answer 208

Prescription-only Medicine – Veterinarian, Pharmacist, Suitably Qualified Person medicines may be prescribed in circumstances where a veterinary surgeon has carried out a clinical assessment and has the animals under his or her care. However, the Veterinary Medicines Regulations provide that POM-VPS may be prescribed in circumstances where the veterinary surgeon, pharmacist or SQP has made no clinical assessment of the animals and the animals are not under the prescriber’s care.

Answer 209

Non-Food Animal – Veterinarian, Pharmacist, Suitably Qualified Person medicines may be supplied in circumstances where the veterinary surgeon or SQP is satisfied that the person who will use the product is competent to do so safely, and intends to use it for the purpose for which it is authorised.

Answer 210

Authorised Veterinary Medicine – General Sales List

Answer 211

The cascade is a risk-based decision tree to aid prescribing on a case-by-case basis. Initially a VS should prescribe a medicine authorised in the jurisdiction where they are practising, for use in the target species, for the condition being treated, and used at the manufacturer's recommended dosage. If no such product exists, follow the cascade. Nb. There is separate guidance on the Cascade for veterinary surgeons practising in England/Wales/Scotland, and for those in Northern Ireland. Please refer to VMD website The treatment in any particular case is restricted to animals on a single holding Any medicine imported from another country must be authorised for use in a food-producing species in that country The pharmacologically active substances contained in the medicine must be listed either for use in NI – in table 1 of the Annex to Regulation (EU) No. 37/2010 (this table replaces Annexes I, II or III of Council Regulation (EEC) 2377/90); for use in GB – in the GB MRL Register as part of the VMD’s Product Information Database. The veterinary surgeon responsible for prescribing the medicine must specify an appropriate withdrawal period The veterinary surgeon responsible for prescribing the medicine must keep specified records

Answer 212

Controlled drugs (CDs) are listed in Schedules 1 to 5 of the Misuse of Drugs Regulations 2001 Veterinary medicines only contain CDs in Schedules 2, 3, 4 and 5 Schedule 1 drugs include drugs such as cannabis or LSD – highly addictive, no therapeutic value Schedule 2 CDs have therapeutic value but are highly addictive Licenced examples; Methadone Fentanyl Pethidine Ketamine Schedule 3 includes buprenorphine, barbiturates and some benzodiazepines which are also subject to special prescription writing requirements. Some are also subject to special storage requirements Schedule 4 and schedule 5 drugs have no additional special controls Ketamine WAS Schedule 4 Since November 2015 reclassified as Schedule 2 Now subject to full schedule 2 legal requirements Schedule 2s: Obtained from wholesalers providing a signed prescription has been issued by the requesting veterinary surgeon Must keep requisition records for at least 2 years Schedule 2 or 3 CDs ; written prescription must be signed by the person issuing it which may be hand-written, typed in a computerised form or computer generated. This prescription is only valid for 28 days. Repeat dispenses on the same prescription are not allowed with schedule 2 or 3 drugs Recommended that you keep a copy of a CD requisition to assist in complying with the law on wholesale supply RCVS considers that a veterinary nurse may draw up and administer a CD Provided the veterinary surgeon Prescribed the drug to a specific animal Decided on the dose Authorised that it be drawn up and is confident that the veterinary nurse is competent to draw up and administer the prescribed dose A veterinary surgeon does not need to be present when the drugs are drawn up or administered but the legal responsibility for the supply of the CDs remains with the veterinary surgeon Recommended to have a standard operating procedure Veterinary nurses may administer CDs out of hours when there is no vet on the premises A veterinary nurse is not able to decide to give a CD or change the dose (i.e. make prescribing decisions) without the instructions of a veterinary surgeon

Answer 213

Complete records of Schedule 2 CDs must be kept in a Controlled Drugs Register (CDR) CDR = either a computerised system or a bound book separated into each class of drug with a separate page for each strength and form of that drug at the top of each page. Loose leaf registers or card index systems are not allowed CDR entries must be In chronological order, made in ink or in a computerised form in which every entry can be audited, and made on the day of the transaction The book must be kept at the premises to which it relates and be available for inspection at any time It must be kept for a minimum of two years after the date of the last entry The CDR must record for all CD purchased and supplied The date supply received, name and address of supplier and quantity received The CDR must record for all CDs administered or supplied The date supplied, name and address of person supplied, details of the authority to possess (prescriber or licence holder’s details) and the quantity supplied

Answer 214

Schedule 2 and Schedule 3 CDs containing buprenorphine must be kept in a locked container which is constructed and maintained to prevent unauthorised access to the drugs and can only be opened by a veterinary surgeon or other authorised person The room housing this container should be lockable and tidy to avoid drugs being misplaced CD container keys should not be kept with keys to other parts of the building The room should not normally be accessible to clients Any returned CDs should not be re-used and should be destroyed according to regulations.

Answer 215

Analgesics may act at different sites They may act at the site of injury and decrease the pain associated with an inflammatory reaction (e.g. NSAIDs) They may alter nerve conduction (e.g. local anaesthetics) They may modify transmission in the dorsal horn (e.g. opioids & some antidepressants) They may affect the central component and the emotional aspects of pain (e.g. opioids & antidepressants)

Answer 216

Natural (opiate) and synthetic (opioid) drugs Endogenous opiates Opioid receptors identified; mu, delta, kappa, nociceptin Effect depends on dose, route, species, stimulus etc CVS effects, pruritis, urinary retention, ileus, pancreatic duct, temperature, miosis, mydraisis, vomiting & nausea, mania & respiratory depression? MOSTLY IN PEOPLE

Answer 217

The most efficacious opioid at relieving pain It is a full agonist at mu, delta and kappa receptors Not licensed. (CD II) Nevertheless still used widely CRIs and epidurals plus horses

Answer 218

A synthetic mu agonist (full) & affinity for NMDA receptor Has effects as a norepinephrine and serotonin reuptake inhibitor Following IV - duration of action is approximately 4 hours (can be longer with sc) Vomiting – not usually Use as premed, for sedation, intra op (v slow IV), on recovery, and as CRI Poor oral availability Licensed for dogs and cats. CD II

Answer 219

Synthetic agonist at the mu receptor Also shown to block sodium channels Agonist at alpha 2 B subtypes Negative inotropic effects but tends to increase heart rate NOT IV- Can induce histamine release Pethidine should not be administered to dogs receiving selegiline - Monoamine oxidase inhibitor + pethidine ≡ serotonin syndrome CD II (licensed for dogs, cats, horses) Spasmodic colic DOA ≈ 90 minutes

Answer 220

Fentanyl is a highly lipid soluble short acting mu opioid agonist. CD II Uses: Intraoperatively as bolus, with peak analgesic effects occurring in 3-5 minutes At induction with a benzodiazepine For compromised patients, fentanyl + benzodiazepine may be sufficient for intubation CRIs are very effective Transdermal fentanyl patches Respiration slows or may cease following a bolus - Bradycardia can be significant Fentanyl ‘spot on’ licensed for dogs (Recuvyra)

Answer 221

has been used in dogs (often with paracetamol) for mild to moderate pain (post op)

Answer 222

antagonism of pure mu opioids

Answer 223

Tramadol is popular! But there is a lack of data in dogs, better in cats It is commonly prescribed to humans – now licensed in dogs It is a synthetic analogue of codeine; it is a low potency mu selective partial agonist PRODRUG with LIMITED metabolism in dogs It has an alpha 2 adrenergic effect and inhibits 5HT reuptake CDIII Very limited value in dogs but useful in cats

Answer 224

a partial agonist with a strong affinity for mu receptors (mild kappa antagonist) Highly potent but not as efficacious as pure opioids Peak effect IV admin 45-60mins Mild to moderate pain, good sedation, long duration of action, preservative in multi dose vials Licensed for dogs and cats and horses OTM route works v well (cats>dogs)

Answer 225

is a kappa opioid agonist and mu antagonist (short-medium duration) Its actions differ to that of the other opioids Available as oral form (Torbutrol) Useful in combination with acepromazine for sedation e.g. cardiac patients Licensed for dogs, cats & horses Antitussive- suppress coughing LIMITED ANALGESIA

Answer 226

Lidocaine Prilocaine (+lidocaine) Bupivicaine Mepivicaine Ropivicaine Etidocaine Amethocaine Proparacaine Cocaine

Answer 227

Lidocaine Prilocaine (+lidocaine) Bupivicaine Mepivicaine Ropivicaine Etidocaine Amethocaine Proparacaine Cocaine LAs are weak bases and largely ionised at physiological pH. ?Problem in inflamed tissue Their speed of onset is inversely related to their degree of ionization. ?Longer to start working in inflamed tissue Their duration of effect is directly related to their degree of protein-binding. Their potency is related to their lipid solubility.

Answer 228

Inhibit prostaglandin production by interfering with cyclo-oxygenase (COX) COX 1, 2 Now thought also to have a spinal action Synergistic with other drugs iv, im, sc, poSome licensed for pre-operative use Carprofen and meloxicam have revolutionized perioperative pain management in UK in last 3 decades Carprofen Firocoxib Meloxicam Deracoxib Etodolac – Ketoprofen Cimicoxib Mavacoxib Robenacoxib Grapiprant Paracetamol ? and codeine (opioid) Phenylbutazone Tolfenamic acid Tepoxalin* Vedaprofen Keterolac Aspirin Licensed NSAIDs for horses- Phenylbutazone Suxibuzone Firocoxib Meloxicam Flunixin meglumine Vedaprofen Carprofen Traditional NSAIDs are contraindicated in patients with: Renal or hepatic insufficiency Hypovolaemia Congestive heart failure & pulmonary disease Coagulopathies, active haemorrhage Spinal injuries Gastric ulceration Concurrent use of steroids Shock, trauma (esp head trauma) Pregnancy

Answer 229

Prostaglandin (PG) synthesis attributable to COX 1 along length of GIT PGs play a role in regulating renal blood flow, reducing vascular resistance & enhance organ perfusion COX 1 is found in neurones and in the foetus, amniotic & uterine tissue Blood platelets contain COX 1

Answer 230

Piprant class NSAID Non-cyclooxygenase inhibiting non-steroidal anti-inflammatory drug Licenced for treatment of mild to moderate osteoarthritis pain and inflammation in dogs Has been called ‘next step’ when ‘traditional’ NSAIDs are not tolerated Approved for use in dogs from 9 months of age and favourable safety profile Once daily administration (chewable tablet) – 2mg/kg Adverse events include vomiting, diarrhoea, decreased appetite and tiredness. Often dogs will adjust but washout between NSAIDs essential Not for use in cats

Answer 231

antagonism of pure mu opioids

Answer 232

Paracetamol: 10 - 15 mg/kg PO two to three times daily. Is it a NSAID? Analgesic & antipyretic Mechanism of action unknown! Thought to inhibit COX-3(??) but recent data suggest there may be another site

Answer 233

bind to alpha 2 receptors Receptors widespread Drugs have other actions (sedation, ↓HR etc) Systemic, epidural, peripherally Synergism with LA’s Dogs/cats- Medetomidine (45 minutes) Dexmedetomidine (45 minutes) Horses Xylazine (30 minutes) Detomidine (45 minutes) Romifidine (60-70 minutes) Cattle - Xylazine Detomidine Very useful drugs Sedative action Analgesic (& reduce MAC) Compatible with other drugs & potential to antagonise (atipamezole), IV, IM, epidurally, buccally (detomidine) Small volume Alpha 2 receptors 3 subtypes (4) A,B,C Diverse sites: CNS & PNS Hyper (B) then normo/hypotension (A) Decreased CO & HR, increased SVR Respiratory depression Increased urine production Decreased GI motility Decreased surgical stress response Hyperglycaemia, GH enhanced Thermoregulation affected Sweating Sedation including standing sedation for equine/large animal Premedication PIVA/TIVA Epidural Rescue analgesia One of the few classes of drugs with an antagonist- atipamazole

Answer 234

As induction agents As analgesics peri op Ketamine for fractious cats (sprayed in mouth) Very versatile Will improve the patient’s post op comfort It has been shown that at low doses ketamine can prevent the ’wind up’ and sensitisation of dorsal horn cells 0.5mg/kg after induction Can be used in the pre-med CRI e.g. Add 60mg ketamine to 1L LRS and administer at 10ml/kg/hr to dogs intra op (10mcg/kg/min)

Answer 235

inhibits cell wall synthesis and gram positive bacteria

Answer 236

inhibits cell wall cynthesis broad spectrum

Answer 237

inhibits cell wall synthesis skin ointment for gram positive bacteria

Answer 238

inhibits cell wall synthesis broad spectrum

prep for clinical practice spot exam Flashcards

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