Anaesthetic protocol for GDV

Re: Anaesthetic protocol for GDV

John Flynn — Thu, 26 Feb 2015 13:16:00 GMT

drug-wise, I usually go iv fluids first rapidly, then methadone maybe 0.5mg/kg im/iv (+/- atropine if heart rate goes low-ish), midazolam 0.2mg/kg IM/IV, pre-oxygenate 5mins and then etomidate to iv effect (usually need very little maybe 0.5mg/kg) to allow intubation and on to gas.

I'll pass a stomach tube +/- xray either before or after indcution based on patient temperament/depression. Sometimes needle depress first/concurrently.

I usually spend a while with a stomach tube lavaging out stomach with warm water either pre- or peri-surgery (if I couldn't pass a tube before surgery will usually do so during surgery) to empty it fully.

Re: Anaesthetic protocol for GDV

Starling — Thu, 26 Feb 2015 12:40:15 GMT

In my mind methadone is a fantastic option but never used it for gdv. Wich dosage do you use? wich route of administration?

Re: Anaesthetic protocol for GDV

Andrew Mellor — Fri, 02 Jan 2015 16:34:40 GMT

[quote user="Jenny Smith"]Drugs wise I use a methadone pre-med, I will usually give this as I place the iv to start fluids. They must be massively painful so I give them the benefit of the doubt. Then do a proprofol/midazolam co-induction and iso/o2 from there.[/quote]

My only concern with methadone or morphine is the side effect of apnoea that is very common, in a dog already compromised, I give methadone but not until stomach de-rotated and circulation more normal.

Re: Anaesthetic protocol for GDV

Jenny Smith — Thu, 01 Jan 2015 22:46:17 GMT

Fluid bolus until shock signs resolving and lactate reducing (if lactate readings available, if not just go off heart rate and pulse quality). I will go for big orange catheters in both cephalics for the shock boluses, then bung one and continue fluids through the second as needed during GA.

I prefer percutaneous decompression as well, I don't like wrestling with a dog to stomach tube it! But, if it's a relaxed well behaved patient I will have a go

Drugs wise I use a methadone pre-med, I will usually give this as I place the iv to start fluids. They must be massively painful so I give them the benefit of the doubt. Then do a proprofol/midazolam co-induction and iso/o2 from there.

Jenny

Re: Anaesthetic protocol for GDV

Yantha Smyth — Wed, 31 Dec 2014 11:35:34 GMT

[quote user="Anthony Dennison"]

[quote user="Michael Woodhouse"]

Is anyone else routinely stomach tubing dogs before GA? I saw two GDVs as a student and this was how they were managed so I have never induced anaesthesia without getting some gas off and giving some fluids. Place a ~1/3 full roll of cohesive bandage into mouth to protect the tube - tolerated and successful in 2/3 of dogs. The remainder get a 14g needle to deflate.

Not seen one for ages.....

[/quote]

I do this too, or at least attempt to. Will usually take radiographs pre-and post too to see if it's made any difference

[/quote] Yes I do that too. In the few that I have come across, this has always been successful, and brings substantial relief, buying more time for other shock stabilisation before induction and surgery.

Re: Anaesthetic protocol for GDV

Hannah Wynne Richards — Tue, 30 Dec 2014 14:43:05 GMT

Hartman's in both cephalics, decompress with 1 and 1/2" cow (grey) needle, induce with alfaxan.

Wynne

Re: Anaesthetic protocol for GDV

Anthony Dennison — Mon, 29 Dec 2014 11:56:38 GMT

[quote user="Michael Woodhouse"]

Not seen one for ages.....

[/quote]

I do this too, or at least attempt to. Will usually take radiographs pre-and post too to see if it's made any difference

Re: Anaesthetic protocol for GDV

Glen McIntosh — Mon, 29 Dec 2014 01:49:55 GMT

No, I routinely use percutaneous decompression along with iv fluids and opioid analgesia as my initial stabilisation regimen.

I will only place a stomach tube after I have derotated the stomach in surgery.

It is my experience that percutaeous decompression is safe (if done with appropriate caution), well tolerated by the concious dog and very effective - that is, it works every time.

Where as stomach tubing, even in the sick and collapsed GDV patient, is somewhat stressful for everyone involved, especially the conscious patient, is often unsuccessful (more than 1/3 of the time in my experience), and occasionally dangerous to the patient - over vigourous tubing can perforate necrotic areas of stomach, and, in theory, the stress involved in passing the tube could make the whole inflammatory situation associated with this disease just that little bit worse.

So my view is: why bother?

But I know the RVC prefer to stomach tube first.

I disagree, for the reasons stated above, but I have no evidence other than my own experience.

Ultimately, either approach probably achieves the same outcome - stomach decompression, and the differences to overall survival from use of either approach are probably marginal.

Re: Anaesthetic protocol for GDV

Braden Collins — Mon, 29 Dec 2014 01:23:07 GMT

My normal approach is IV fluids in both front legs as fast as I can get them in, percutaneous decompression with 12-14G IV canulas, and induction with Diaz/ket. I like diaz/ket as it is a rapid bolus infection so I can get airway control very rapidly. Pass a stomach tube at this point if possible, otherwise continue percutaneous decompression until sufficiently deflated.

Re: Anaesthetic protocol for GDV

Michael Woodhouse — Mon, 29 Dec 2014 01:18:31 GMT

Not seen one for ages.....

Re: Anaesthetic protocol for GDV

Glen McIntosh — Mon, 29 Dec 2014 01:05:07 GMT

[quote user="mariette asselbergs"]

[quote user="Hannah Wynne Richards"]

Why not alfaxan?

What's the point of oxyglobin when there hasn't been blood loss?

Wynne

[/quote]

Sorry I missed this reaction to my question.

A German colleague of mine in Emergency OOH uses it. I suppose as support in oxygen carrying capacity in a severely shocked, hypovolaemic dog? Also helping with hypovolaemic shock to increase circulating volume and keep it in the vascular system?

[/quote]

Dogs with GDV are usually in severe shock, but this shock is caused by compression of the caudal vena cava by the dilated stomach, thereby markedly decreasing venous return and, subsequently, cardiac output. There is often some mild to moderate intra - abdominal bleeding associated with GDV, usually associated with tearing of small stomach vessels or splenic vessels, but I have never seen it reach a severity that would require blood product transfusion or oxyglobin administration, for the purposes of compensating for acute blood loss.

Decompression of the dilated stomach, either via percutaneous decompression using a needle trochar, or via stomach tubing, along with boluses of crystalloids, will almost invariably result in near complete resolution of the shock and rapid stabilisation.

So, unless there is some other mechanism at work, I can only see a marginal value in the use of oxyglobin in these cases that may only result in a marginal (if any) improvement in outcomes for these cases, and probably insufficient to justify the high costs associated with using oxyglobin.

This is only my opinion though, based on my experience. This is the type of question that can really only be answered by a well designed study and evidence based medicine, not opinion or even anecdotal experience.

Maybe the studies have already been done and I am just not aware of them - I would be grateful if somebody would post the references if they are aware of any.

Having said that, use of appropriate doses of oxyglobin are very unlikely to cause any harm, and may help in more subtle ways in treatment of the severe inflamatory and other processes that may be ongoing in GDV even after initial stabilisation.

Re: Anaesthetic protocol for GDV

mariette asselbergs — Sun, 28 Dec 2014 19:32:32 GMT

[quote user="Hannah Wynne Richards"]

Why not alfaxan?

What's the point of oxyglobin when there hasn't been blood loss?

Wynne

[/quote]

Sorry I missed this reaction to my question.

Mariette

[quote user="Hannah Wynne Richards"]

Why not alfaxan?

What's the point of oxyglobin when there hasn't been blood loss?

Wynne

[/quote]

Re: Anaesthetic protocol for GDV

Hannah Wynne Richards — Tue, 16 Dec 2014 18:16:46 GMT

Sevo No nitrous

Wynne

Re: Anaesthetic protocol for GDV

Andrew Mellor — Tue, 16 Dec 2014 18:01:17 GMT

In what way control? I can understand not changing back once you have moved as when you have different products/ protocols that is when accidents are more likely to happen.

Wynne are you on iso or sevo and do you use nitrous oxide?

Re: Anaesthetic protocol for GDV

Hannah Wynne Richards — Tue, 16 Dec 2014 17:41:45 GMT

Yes

Controllability.

My nurse would kill me if I went back to propofol, and I'm a coward.

Wynne

Re: Anaesthetic protocol for GDV

Andrew Mellor — Tue, 16 Dec 2014 17:34:36 GMT

[quote user="Hannah Wynne Richards"]

Why not alfaxan?

What's the point of oxyglobin when there hasn't been blood loss?

Wynne

[/quote]

so educate us why should we be using alfaxan - I've heard the hard sell but genuinely what are the advantages / disadvantages in practice and is this all you use now ?

Re: Anaesthetic protocol for GDV

Hannah Wynne Richards — Tue, 16 Dec 2014 17:15:08 GMT

Why not alfaxan?

What's the point of oxyglobin when there hasn't been blood loss?

Wynne

Re: Anaesthetic protocol for GDV

mariette asselbergs — Tue, 16 Dec 2014 17:07:31 GMT

Who uses oxyglobin?

Mariette

Re: Anaesthetic protocol for GDV

Andrew Mellor — Tue, 16 Dec 2014 17:05:13 GMT

+1 for fluids +++ ofter 2 lines and propofol to effect and then iso /o2 once I know stomach deflated and dog will survive ie stomach not ruptured or necrotic I will give nsaid and comfortan usually half dose and repeat 4 hours later. I usually give metoclopramide by intravenous infusion to try and get some motility going in the stomach wall too.

Re: Anaesthetic protocol for GDV

Richard Carter — Fri, 12 Dec 2014 17:48:25 GMT

Presuming you talking about gdv as an emergency so drip, propofol without premed and isoflo asap to deflate stomach asap to get circulation, breathing and pain as near back to normal asap before starting to think about whether it is going to survive. Will give vetergesic at some point if/ when some indication that success may be a possibility

may need to ventilate if cannot reduce stomach fairly rapidly.