Cat with generalised subcutaneous emphysema

Re: Cat with generalised subcutaneous emphysema

Dawn Sheppard — Fri, 02 Nov 2012 17:07:27 GMT

The V-gels are already used in over 26 countries around the world and have 4.5 years of R&D behind them. They are species-specific and mirror the landscape of the peripharyngeal area, meaning they do not touch the larynx or enter the trachea. The soft gel material is cushioned against the periglottic area and produces a secure seal enabling the anesthetist to provide IPPV where necessary. The ease of use makes them the device of choice for a lot of procedures, however they are another tool in your tool box and I would hope that every anaesthesia case is individually assessed as to the drugs and devices that suit. ETT have been around for decades, but are single-use human devices that have been crossed over into the veterinary market. The human upper airway tract has a 90 degree angle and as such the ETT are curved inorder to cope with this angle, because our veterinary patients do not have this angle, we are potentially causing trauma when the tube is placed/rotated as the end of the ETT is scraping the internal aspect of the trachea. We are also narrowing the airway and causing a much higher airway resistance... try breathing down a straw yourself!! Our rabbits don't like breathing at the best of times! There is also H&S issues with gas leakages around ETT and our pregnant staff will appreciate the safety aspect of the non-leaking from the v-gel seal, as well as the cost of the excess Oxygen used! There are many testomonies from anaesthsia certificate holders as to the huge benefits of these devices... don't knock them before you have seen the benefits for yourselves - have them demo'd at your surgery

Re: Cat with generalised subcutaneous emphysema

Rajat — Wed, 11 Jul 2012 17:37:00 GMT

[quote user="Evelyn Barbour-Hill"]No, it was used for induction for anything at all (in cats, of course). [/quote]

I see. I was under the impression Saffan was considered safer because a cat spay could be done 'under Saffan' without the need for other drugs. I used it a few months after qualifying (I think!).

[quote user="Evelyn Barbour-Hill"]

For myself, i'm really not sure why people are so apprehensive about the feline larynx.

[/quote]

I agree entirely. Most of us intubate cats every day.. My comment about the FKM drip cf intubation for an orthopaedic op was meant to be tongue in cheek. Must have one of those smilies added to the list!

Re: Cat with generalised subcutaneous emphysema

Evelyn Barbour-Hill — Tue, 10 Jul 2012 23:34:34 GMT

[quote user="Rajat"]Again, I have the feeling Saffan was used mainly for cat spays rather than ops with higher ASA statuses..just a feeling tho[/quote]

No, it was used for induction for anything at all (in cats, of course). Many of us preferred it to thiopentone despite its disadvantages.

[quote user="Rajat"]

don't see why an orthopaedic op in a youngish or ASA I-II category cat couldn't be done with Alfaxan TIVA or Fentanyl ketamine medetomidine CRI..?! Avoids that pesky larynx ...

[/quote]

Ah, there's nothing new under the sun, what goes around comes around and similar cracker-barrel phrases. Apart from the very occasional introduction of a really new drug, I doubt if there's any anaesthetic technique that hasn't been tried, briefly fashionable, loved by some and hated by others. For myself, i'm really not sure why people are so apprehensive about the feline larynx.

Re: Cat with generalised subcutaneous emphysema

Rajat — Tue, 10 Jul 2012 23:07:14 GMT

[quote user="Julian Earl"]The question though is whether intubating a cat castrate or even a spay makes the anaeshetic safer for the cat.[/quote]

Yes a pertinent question. 100% O2 can be given by facemask and SPO2 monitored so that's oxygenation taken care of. for ventilation unless capnography is being utilised we cannot tell if it is adequate or not.Also the importance of having an airway in place and secure is if things go wrong then immediate IPPV can be instituted.

Note the CESPAF study states "Problems with airway maintenance and inadequacy of ventilation represent the principal
factors resulting in death"- not just talking about cats but animals in general. I can see how intubation could cause problems but can also see how ventilation could be at best difficult without having a tube in the airway

and

" After adjusting for health status, the intended duration was associated with a 5-fold increase in odds for procedures over 30 minutes"

andalso (paraphrasing) '...the vast majority of practices intubated cats undergoing General Anaesthesia..'

All makes me wonder, if despite the higher deaths reported in cats, most practices intubated all proceudres other than castrates and maybe the odd spay and hence the disproprtionate mortality rates. I don't know if this info is hidden somewhere in D Brodbelt's excellent thesis, I just don't have time to go thru it all!

[quote user="Julian Earl"] If the procedure is a longer one, say an orthopaedic, then clearly intubation is necessary (unless people do those under triple?) but for short elective procedures, if you need access to a vein, primarily for volume replacement as far as I can see, then something is seriously wrong with your castration/spay technique.[/quote]

Like Gillian said IV access is not just for volume replacement. Personally, I prefer to have IV access if doing a GA.Routine BP measurement in all GA'd patients has shown me how unpredictable similar patients can be in response to the same dose of the same drugs!

[quote user="Julian Earl"]The only argument I can see is whether supplemental intravenous anaesthesia with alfaxalone is better than inhalational anaesthesia if, for example, the spay takes longer than expected? My understanding is that the former is preferable to the latter.[/quote]

Again, I have the feeling Saffan was used mainly for cat spays rather than ops with higher ASA statuses..just a feeling tho

I don't see why an orthopaedic op in a youngish or ASA I-II category cat couldn't be done with Alfaxan TIVA or Fentanyl ketamine medetomidine CRI..?! Avoids that pesky larynx ...

Agree with David M totally about Bupe..! And for those who haven't, give trans mucosal bupe a try in kitties, esp those fractious(often painful) older cats - works brilliantly!

Re: Cat with generalised subcutaneous emphysema

David Mills — Tue, 10 Jul 2012 22:25:08 GMT

[quote user="Thomas Johnson"]

[quote user="David Mills"]

Here we routinely use quad d/t/k/buprenorphine esp in youngsters strays and nasties.

[/quote]

I do most of my cat spays under triple. I'm not sure of the benefits of adding buprenorphine though. Isn't one opiate going to antagonise the other?

[/quote]

I think buprenorphine is one of the least well understood drugs by vets. There is a myth that as a partial agonist it occupies all mu receptors and that's it, no more analgesia until it wears off 6-8 hours later. This is false. Yes it occupies receptors with a higher affinity than any other opiod but at doses given not all receptors are occupied and it is perfectly fine to top up analgesia with a full mu opiod. Buprenorphine reaches a plateau of analgesia which can't be topped up to any more effect with dupe. Butorphanol in the quad combo is mainly used for sedation as it is rapidly absorbed from IM and allows significant reduction in ket/medetomidine whilst providing anaesthesia properties with minimal/no negative CVP effects. The buprenorphine takes 30-45minutes for full effect i.e. it needs to be given at induction otherwise there is little analgesia by the time the cat wakes up. I personally do not consider nsaid adequate alone in the preoperative period.

Re other things above, ketamine is relatively cardiotoxic in its effects and associated with a higher preoperative mortality when used as sedation/GA; this, annoyingly, is despite its relatively mild CV depressive effects under GA (unless a high sympathetic tone at induction, whereby HR will go through the roof)

Re: Cat with generalised subcutaneous emphysema

Evelyn Barbour-Hill — Tue, 10 Jul 2012 21:54:26 GMT

[quote user="Julian Earl"]The question though is whether intubating a cat castrate or even a spay makes the anaeshetic safer for the cat. If the procedure is a longer one, say an orthopaedic, then clearly intubation is necessary (unless people do those under triple?) but for short elective procedures, if you need access to a vein, primarily for volume replacement as far as I can see, then something is seriously wrong with your castration/spay technique.[/quote]

I usually put the endotracheal tube in the trachea!

Re: Cat with generalised subcutaneous emphysema

Gillian Mostyn — Tue, 10 Jul 2012 21:23:53 GMT

[quote user="Julian Earl"]but for short elective procedures, if you need access to a vein, primarily for volume replacement as far as I can see, then something is seriously wrong with your castration/spay technique.[/quote]

I think venous access is more about quick intravenous access for drugs (such as in an emergency situation) than about volume replacement, where you are likely to have a little more time to place the canula.

Re: Cat with generalised subcutaneous emphysema

Julian Earl — Tue, 10 Jul 2012 17:48:55 GMT

[quote user="Rajat"]

On the note of tubing and triples- I don't think the CEPSAF study differentiated between tubing cats of ASA grade I-II vs III-V (the latter having higher mortality rates) .I suspect the cats not intubated had lower ASA scores and were the routine castate/spays vs the intubated cats which may have had longer more complex procedures. Not sure I agree with an approach of only intubating the 'risky' or 'non routine' anaesthetics- in my little experience I find anaesthetic complications bite you in the butt hardest when you're not expecting it...although I do think intubating cats is 'riskier' than in dogs due to potential for laryngospasm, Interestingly the use of ketamine was associated with higher risk whereas medetomidine with a lower risk in the CEPSAF study.I wonder, being wonderfully statistically ignorant that I am, f this means then the risk is negated when both are used together? kidding of course!

Best

Raj

[/quote]

The question though is whether intubating a cat castrate or even a spay makes the anaeshetic safer for the cat. If the procedure is a longer one, say an orthopaedic, then clearly intubation is necessary (unless people do those under triple?) but for short elective procedures, if you need access to a vein, primarily for volume replacement as far as I can see, then something is seriously wrong with your castration/spay technique. For a longer procedure, then the anaesthesia poses a greater risk but so be it if the animal needs that procedure.

The only argument I can see is whether supplemental intravenous anaesthesia with alfaxalone is better than inhalational anaesthesia if, for example, the spay takes longer than expected? My understanding is that the former is preferable to the latter.

Re: Cat with generalised subcutaneous emphysema

Rajat — Tue, 10 Jul 2012 17:11:45 GMT

[quote user="Thomas Johnson"]Isn't one opiate going to antagonise the other?[/quote]

The current thinking is that when torb leaves receptors buprenorphine will occupy them. Its affinity for the opioid receptor is thought to be super strong and torbugesic is quite short acting and quite a weak analgesic anyways. There have been opinions on feline analgesia which indicate it is probably not appropriate for anything other than minor pain. [http://jfm.sagepub.com/content/12/4/247.abstract] I find it great for sedation!

I like using torb because it 'bridges' some of the analgesic gap in those where bupe hasn't kicked in yet (but I try not to cut till 35-45 mins post premed) but also because it makes the animal sleepier and less excitable than with bupe alone. having said that if using triple/quadruple it shouldnt make a difference (as medetomidine and ketamine should provide enough sedative 'punch')

Best

Raj

Re: Cat with generalised subcutaneous emphysema

Thomas Johnson — Tue, 10 Jul 2012 11:47:48 GMT

[quote user="David Mills"]

Here we routinely use quad d/t/k/buprenorphine esp in youngsters strays and nasties.

[/quote]

I do most of my cat spays under triple. I'm not sure of the benefits of adding buprenorphine though. Isn't one opiate going to antagonise the other?

Re: Cat with generalised subcutaneous emphysema

Simon Neuhoff — Sat, 07 Jul 2012 14:22:39 GMT

+1 for triple combo. Easy, safe, effective and quick.

Re: Cat with generalised subcutaneous emphysema

David Mills — Fri, 06 Jul 2012 22:35:46 GMT

One for the Aussies but alfaxalone IM works fantastically well and gives around 30 minutes of surgical GA - easily enough to do a spay. Same dosage. Licensed for this route in Aus, though not here; may be a useful alternative to triple combo and cheaper, and a decent case made for its use off-cascade.

Equally perplexed about triple combo. Here we routinely use quad d/t/k/buprenorphine esp in youngsters strays and nasties. Am not normally one to side with the old guard but there is a phenomenal amount of pissing around goes on preparing for GA - stack em up and have them knocked out by a nurse IM whilst closing up the previous, with decent nurses can normally get through 5 an hour cat spays minimum. A fantastic combination.

Re: Cat with generalised subcutaneous emphysema

Julian Earl — Fri, 06 Jul 2012 21:41:18 GMT

[quote user="Lorna McHardy"]

[quote user="Julian Earl"]

[/quote]

I was never a fan of Saffan, back when it was the drug of choice. The cats far too often ended up with bright red ears and puffy feet, and once I had one whose throat swelled up. Not good.

[/quote]

I saw plenty of cats with swollen paws and ears, and twenty years ago we had a practice cat that had no ears after castration - the owners refused to take it home after the pinnae sloughed off and the boss felt obliged to keep the cat; "Saffan" then lived a long and happy life around the practice. Anyway...

[quote user="Anthony Todd"]

[quote user="Lorna McHardy"]I was never a fan of Saffan[/quote]

Is it still around; wasn't there a rather devastating survey from Glasgow uni showing fatalities of 1 in 800 which was greater than anything else ?[memory]

[/quote]

the paper I am thinking of showed it to be safer (i.e. fewer deaths) than other anaesthetic methods regardless of this oedema. I am 99% sure it was Saffan and not Alfaxan although it was a relatively recent paper so maybe that is wrong. Still, injectable alfaxalone was safer than inhalational in cats.

Re: Cat with generalised subcutaneous emphysema

Anthony Todd — Fri, 06 Jul 2012 20:40:04 GMT

[quote user="Lorna McHardy"]I was never a fan of Saffan[/quote]

Is it still around; wasn't there a rather devastating survey from Glasgow uni showing fatalities of 1 in 800 which was greater than anything else ?[memory]

Re: Cat with generalised subcutaneous emphysema

Lorna McHardy — Fri, 06 Jul 2012 20:03:46 GMT

[quote user="Mark Rowland"][quote user="Evelyn Barbour-Hill"]

[quote user="Julian Earl"]I argue the case with our newer graduates that cat castrations do not need inhalational anaesthesia, nor full surgical preparation. It is a five minute procedure at the most. No infections, no complications, no laryngeal trauma - injectable anaesthesia, rapid scrub, cut, haemostasis and done. Why increase the risk by intubating?[/quote]

[quote user="Julian Earl"]Just don't get me on to compulsive intravenous catherisation of these ops as well...[/quote]

You're a man after me own heart.

[quote user="Julian Earl"]The point is that triple is okay as well[/quote]

And propofol and isoflurane is okay as well.

[/quote] +1 for the above

[/quote]

+2.... just not with Saffan :0))

Re: Cat with generalised subcutaneous emphysema

Lorna McHardy — Fri, 06 Jul 2012 20:00:43 GMT

[quote user="Julian Earl"]

[/quote]

I was never a fan of Saffan, back when it was the drug of choice. The cats far too often ended up with bright red ears and puffy feet, and once I had one whose throat swelled up. Not good.

Re: Cat with generalised subcutaneous emphysema

Lorna McHardy — Fri, 06 Jul 2012 19:57:49 GMT

[quote user="Hannah Wynne Richards"]

I was so disgusted at Micheal's posting about spaying cats under triple only that I nearly red-starred him-then decided that would be cowardly Anthony and I are both old enough to have dinosaur attitudes-but we've both moved on (considerably) from that

Wynne

[/quote]

Now I'm really baffled. What is so wrong with spaying cats under triple?

Re: Cat with generalised subcutaneous emphysema

Mark Rowland — Fri, 06 Jul 2012 17:50:48 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Julian Earl"]Just don't get me on to compulsive intravenous catherisation of these ops as well...[/quote]

You're a man after me own heart.

[quote user="Julian Earl"]The point is that triple is okay as well[/quote]

And propofol and isoflurane is okay as well.

[/quote] +1 for the above

Re: Cat with generalised subcutaneous emphysema

Alet Engelbrecht — Fri, 06 Jul 2012 17:49:23 GMT

[quote user="Julian Earl"] It is a five minute procedure at the most.[/quote]

And that's a complicated one...

Years ago, a vet I know went to the trouble of working out the most profitable procedure in his practice (it must have been a slow day) - cat castrations came out tops by far. We could all be just a couple of toms away from being rich!

Re: Cat with generalised subcutaneous emphysema

Evelyn Barbour-Hill — Fri, 06 Jul 2012 17:37:15 GMT

[quote user="Julian Earl"]Just don't get me on to compulsive intravenous catherisation of these ops as well...[/quote]

You're a man after me own heart.

[quote user="Julian Earl"]The point is that triple is okay as well[/quote]

And propofol and isoflurane is okay as well.

Re: Cat with generalised subcutaneous emphysema

Julian Earl — Fri, 06 Jul 2012 17:19:58 GMT

[quote user="James Laidlaw"]

[quote user="Hannah Wynne Richards"]

Wynne

[/quote]

It happens regularly at charity clinics, ideally they should still be intubated in case, but I've worked in places since 2005 when I arrived in the UK that still do this and never had a problem. I prefer to intubate (even when doing castrates) but it's nothing to be disgusted by. I guess if people are paying a lot for the procedure they need to know what they are getting though - usually these have been significantly cheaper (and significantly further from London) when I have seen them done this way.

Given the choice personally - I'd always put a tube in. Even with the ongoing debate in this thread!!!

[/quote]

A good question has indeed arisen: why intubate cat spays or castrates at all?

There have been two "papers" - one a proper paper, JSAP maybe, the other a Vet Times article IIRC - indicating that the safest anaesthetic method for cats is injectable, and specifically alphaxalone/alphadolone, otherwise known as "Saffan". You can argue about longer procedures needing intubation, but all that means is that longer operations are higher risk. It is evidence based medicine to avoid intubation if possible - why do we use LA sprays Because the feline larynx is so sensitive, just like a human one. Therefore perhaps it is best left untouched during surgery if possible.

I argue the case with our newer graduates that cat castrations do not need inhalational anaesthesia, nor full surgical preparation. It is a five minute procedure at the most. No infections, no complications, no laryngeal trauma - injectable anaesthesia, rapid scrub, cut, haemostasis and done. Why increase the risk by intubating?

Spays may need intubation unless one is one of the five minute spayers, which I am not. So, yes, I intubate cat spays, but if all goes smoothly, it is only a precaution and a top-up injectable might be adequate. The point is that triple is okay as well; Alfaxan doesn't last long enough for my spays but a triple does, and also is a potent analgesic combination. With the ketamine they don't lose their swallow reflex anyway, so that avoids one potential complication that has cropped up in this V-gel vs ET tube debate.

As far as I am concerned, the compulsive intubation of these minor ops is not necessarily a forward step.

Just don't get me on to compulsive intravenous catheterisation of these ops as well...

Re: Cat with generalised subcutaneous emphysema

Anthony Todd — Fri, 06 Jul 2012 17:01:05 GMT

[quote user="Hannah Wynne Richards"] spaying cats under triple[/quote]

Um, I thought all the modern vets used triple?? [Dunno why they need to tube them cuffed or unbloody cuffed anyway]

What's so bad about it?

Crikey you're not suggesting that something used today is inferior to something we used back in the day!

Re: Cat with generalised subcutaneous emphysema

James Laidlaw — Fri, 06 Jul 2012 16:59:16 GMT

[quote user="Hannah Wynne Richards"]

Wynne

[/quote]

Given the choice personally - I'd always put a tube in. Even with the ongoing debate in this thread!!!

Re: Cat with generalised subcutaneous emphysema

Hannah Wynne Richards — Fri, 06 Jul 2012 16:46:33 GMT

Wynne

Re: Cat with generalised subcutaneous emphysema

Anthony Todd — Fri, 06 Jul 2012 15:28:32 GMT

[quote user="Rajat"]Best wishes[/quote]

and to you

I'll be happy if the idea of blowing the cuff up with a finite amount of air rather than just until the farting stops is accepted, taught and followed.

Mind you I've found it's a hard one to get across [[as the thread shows!!] and I've found over and over again.

Folk seem to think the cuff should be blown up to exceed the pressure in Mark Cavendish's bike tyres!!

Might make ruptured trachea a legend from now on.