23/5/2021 Maintaining Anesthesia - Veterinary Anesthesia Update - VIN

Maintaining Anesthesia
August 1, 2019 (published)
Nancy Brock, DVM, DACVAA

C S S (or moving a patient to the surgical suite)

☐ Has anesthetic machine in O.R. suite been function/leak tested?

☐ Has the patient’s ETT cuff been properly inflated?
☐ Has the protective eye lubricant been administered?

O F R
For the circle (rebreathing) system (traditional adult, traditional pediatric, Universal F)

Start at 200 mL/kg/minute for 10 minutes, then reduce flow

Flow can be reduced to 10 mL/kg/minute or 500 mL/minute (whichever is the greater
amount)
As oxygen flow is decreased, the delivered concentration of anesthetic gas is also
decreased; adjust vaporizer setting upward unless you want your patient’s plane of
anesthesia to lighten
For the non-circle (non-rebreathing) system

200 mL/kg/minute
DO NOT REDUCE FLOW RATE

I O F R I A D
The Circle System

With the out-of-circle vaporizer (aka precision):

INCREASING the fresh gas flow rates INCREASES the concentration of anesthetic gas
delivered to the patient, but never above the concentration on the vaporizer dial.

DECREASING the fresh gas flow rates DECREASES the concentration of anesthetic gas
delivered to the patient; as flow rate decreases, remember to increase the vaporizer dial
setting unless you intend for the patient’s anesthetic plane to lighten.

With the in-circle vaporizer (aka non-precision; rarely used):

INCREASING the oxygen flow rate DECREASES the concentration of anesthetic gas
delivered to the patient.

Decreasing the oxygen flow rate increases the concentration of the anesthetic gas in the
circuit.

The concentration of gas in the breathing hoses depends in part on the patient’s ventilation;
it DOES NOT necessarily correlate with any setting on the vaporizer dial.
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NOTE: I do not use of in-circle vaporizers for the delivery of potent and volatile anesthetic
gas, such as isoflurane or sevoflurane.

N O F R
General guidelines for circle (rebreathing) systems
Nitrous oxide can be administered at a ratio of 1:1 or 2:1 with oxygen. The maximum benefits of
nitrous oxide are achieved with a ratio of 2:1.

At the beginning of inhalation anesthesia, deliver a nitrous oxide flow rate of 400 mL/kg, with an
oxygen flow rate of 200 mL/kg to rapidly flush room air from the breathing circuit

After 15 minutes you may decrease the total combined flow rate, but always deliver a minimum of
20 mL/kg/minute of oxygen (and do not deliver nitrous oxide at a higher ratio than 2:1)

Caution
Always use an oxygen concentration monitor on the inspiratory side of the breathing
circuit during nitrous oxide delivery
Discontinue nitrous oxide delivery at least 5 minutes prior to extubation

General guidelines for non-rebreathing circuits

Nitrous oxide can be administered at a ratio of 1:1 or 2:1 with oxygen. The maximum benefits of
nitrous oxide are achieved with a ratio of 2:1.

Deliver 500 mL/kg/minute total gas flow (oxygen and nitrous oxide combined)

Caution
Do not reduce flow rate
Discontinue nitrous oxide delivery at least 5 minutes prior to discontinuing oxygen
delivery

M D A
Use a combination of physical signs and vital signs, together, to assess anesthetic depth as well
as changes in anesthetic depth.

Vital signs
Heart rate, blood pressure, breathing rate, breathing depth (aka tidal volume, breath size): As a
rule, all of these parameter values increase as the plane of anesthesia lightens or as nocioception
occurs, whereas they decrease as the plane of anesthesia deepens.

Examples of exceptions this rule:

Heart rate increase MAY indicate hypotension or a buildup of carbon dioxide in the patient’s
circulation
Blood pressure increase MAY indicate a buildup of carbon dioxide in the patient’s circulation
Breathing rate and depth increase MAY indicate a buildup of carbon dioxide in the patient’s
circulation
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Physical signs
In addition to vital signs, two main physical signs to monitor anesthetic depth include:

Jaw tone: The patient should have some detectable amount of tone in the jaw muscles, as
the mouth is opened through its entire range of motion. Note the point at which you
encounter some resistance as you open the mouth as well as how that point changes over
time. As the patient’s plane of anesthesia deepens, the jaw muscles relax.

Palpebral reflex: A patient should have a slight blink in response to the anesthetist’s finger
run along the lower eyelid and touching the medial or lateral canthus. If this is absent, the
patient’s plane of anesthesia may be too deep. Do not touch the cornea.
Use the patient as its own control, gauging relative change over time.

Note that these signs become unreliable whenever alpha-2 agonists are administered for
premedication or perioperatively, as this class of drug causes profound muscle relaxation,
hypertension, and bradycardia. In such instances, end-tidal carbon dioxide values (capnography)
or breathing rate/breath size (movement of the reservoir bag) will provide more reliable anesthetic
depth assessment.

If a patient receives local or regional analgesia in addition to general anesthesia, prominent jaw
tone and a brisk palpebral reflex MAY be acceptable, as a lighter plane of anesthesia is possible
(and appropriate) when sensation at the surgical site is blocked.

Make sure that all measured parameters are in agreement about anesthetic depth; investigate
any contradictory parameters.

Patient movement does not always indicate a light plane of anesthesia. Rhythmic or twitching
movement occasionally occurs with propofol infusion, (dex)medetomidine sedation, and inhalant
anesthesia, and is not a sign of a light plane of anesthesia.

U V
THE VENTILATOR DOES NOT REPLACE THE ANESTHETIST, it only frees that person’s hands
to perform other anesthesia-related tasks.

Mechanical ventilation is not necessarily superior to manual ventilation, it is just less labor
intensive.

For details on leak testing procedures, see Function and Leak Testing the Ventilator.

Volume-cycled ventilators: Select a volume of 10–15 mL/kg per breath

Pressure-cycled ventilators: Choose an inspiratory pressure setting of 12–15 cm H2O for

most dogs and 8–12 cm H2O for cats and cat-sized dogs

NOTE: Pressure settings may need to be increased for obese patients; those with
distended abdomens; open chests; and patients with thoracic masses/fluid.

1. Completely close the exhaust/scavenge valve of the breathing circuit when using the
ventilator. If you do not, the breath will not be delivered to the patient but, rather, will escape
into the scavenge hose.
2. Set the rate to 12 breaths per minute for cats and cat-sized dogs, 10 breaths per minute for
medium-sized dogs, and 8 breaths per minute for large dogs. 
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3. Set the inspiratory time to 1 second (count 1 steamboat or Mississippi).
4. Imagine that you are connected to the ventilator: Does the breathing pattern seem
comfortable?
5. Always visually inspect the patient’s chest to ensure that it is expanding properly with each
breath.
Capnography is helpful in determining if ventilator settings are appropriate.

M I P P V (IPPV)
IPPV is more efficient at delivering anesthetic gas to the patient than spontaneous breathing.
Therefore, before starting IPPV assess depth of anesthesia:

Lower the vaporizer dial setting if you wish anesthetic depth to remain the same
Leave the vaporizer dial setting as is OR increase it if you want to deepen the plane of
anesthesia
Steps

1. Close exhaust (pop-off) valve, either completely or partially. You will likely have to open it
slightly from time to time to allow excess oxygen and anesthetic gas to escape. Alternatively,
a pop-off occlusion valve can be installed on the pop-off valve to allow intermittent and
temporary closure.

NOTE: I do not recommend this valve brand or this valve brand, as there is leakage of
anesthetic gas from them in the occluded position; instead, see my favorite occlusion
valve.

2. Deliver a breath to the patient by gently squeezing the reservoir bag over 1 second (count 1
steamboat or Mississippi).
3. Completely release your hold on the reservoir bag and allow the chest to passively deflate.
Do not maintain pressure on the reservoir bag.
4. Repeat Steps 2 & 3.
5. With each breath, ensure that the patient’s chest is expanding sufficiently. If you do not have
access to capnography, follow these guidelines:
For cats, small dogs, ferrets, rabbits: deliver 12 breaths a minute (a breath every 5
seconds) at a pressure of 8–10 cm H2O
For medium size dogs: deliver 10 breaths/minute (a breath every 6 seconds) at a
pressure of 12–15 cm H2O
For larger dogs: deliver 8 breaths/minute (a breath every 7 to 8 seconds) at pressures
of 15–20 cm H2O
Under some conditions, a higher amount of pressure is needed in order to deliver an
appropriately sized breath; such conditions include: diaphragmatic hernia, abdominal
distention, large mass on the abdominal or thoracic wall, fluid or mass in the thorax,
and open chest during thoracotomy
Assess the degree of chest expansion to determine the proper amount of positive
pressure to apply
Some large breed, deep-chested dogs have very compliant chests and require
surprisingly little pressure for effective breath delivery. This may be difficult to assess
because of their deep chested conformation; these patients can often be effectively
ventilated at 10-12 cm H2O
The best way to select the rate and size of breaths is to evaluate the impact of IPPV
on blood pressure and to monitor etCO2
IPPV may lower a patient’s blood pressure by:
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1. Interfering with venous return to the heart
2. Increasing anesthetic depth
3. Reducing sympathetic tone
In circumstances where the blood pressure decrease is unacceptable, deliver 5 mL/kg boluses of
LRS, and lighten the plane of anesthesia if possible.

If blood pressure does not improve, change the breathing pattern to deliver smaller, more frequent
breaths and, at the same time, allow the etCO2 to increase to as high as 60 mm Hg (if necessary).

M V P
Considerations if the patient is trying to breathe on its own

1. Is the patient too lightly anesthetized? Turn up vaporizer and/or flow meter settings or
administer analgesics or both.
2. Does the patient need more ventilation? This question requires either a capnograph or
respirometer. The size and/or rate of breaths may need to be increased so that:
EtCO2 is below 60 mm Hg on the capnograph
Breath size is at least 10 mL/kg
3. Is the patient receiving adequate oxygen? Check the patient’s mucous membrane colour
and/or hemoglobin saturation by pulse oximetry. Verify the O2 and N2O flows, the reservoir
bag movement, and the patient’s chest movements, blood pressure, and heart rate.
Considerations if the ventilated patient is hypotensive

1. Is the patient excessively deep? Lighten the plane of anesthesia.

2. Consider delivering more frequent and smaller breaths if you need to continue ventilating.
3. Is the patient in need of additional IV fluids? Dehydrated patients will become hypotensive
when ventilated.
4. Consider discontinuing IPPV if possible, while allowing spontaneous breathing to keep the
etCO2 below 60 mm Hg, with only the occasional manually delivered breath.
Weaning a Patient Off IPPV
Two basic methods for weaning a patient off IPPV, whether manual or mechanical (these steps
apply equally to dogs/cats):

Method I
After turning off the vaporizer, continue to ventilate the patient with your regular
intraoperative pattern until the patient shows signs of swallowing and is ready for extubation

NOTE: This weaning technique is my preferred method for most patients as it speeds
up the rate of recovery; if you wish recovery to proceed slowly, use Method II below

Method II
After turning off the vaporizer, gradually reduce the number of breaths per minute until you
are delivering 2 breaths per minute. These two breaths per minute ensure that the patient is
receiving adequate oxygen while the CO2 level in the blood stream slowly rises until it is
high enough to trigger the patient to breathe. At this point, you may stop breathing for your
patient.

NOTE: This weaning technique is best for circumstances in which you would like a
prolonged intubation period and slow recovery.

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P P C L
Provide soft padding at all pressure points
Avoid tilting to the "head down” position, unless you are prepared to provide ventilation; this
position may also promote unwanted passive gastric reflux
Do not place instruments or supports on the patient’s chest
Monitor patients closely for hypoventilation if in sternal recumbency
Disconnect patients from the breathing circuits during repositioning to prevent accidental
kinking of the ETT and/or tracheal mucosal injury
Beware of venous air embolism during surgical procedures on body parts positioned above
the heart (head and neck surgery)

A S Y P
Review with staff members the implications of the differences between sevoflurane and isoflurane.

Sevoflurane is associated with:

Equivalent respiratory depression

A more rapid change in anesthetic depth after a change in vaporizer setting; the difference
between sevoflurane and isoflurane is much greater than the difference between isoflurane
and halothane
A less irritating odor, which may improve the quality of mask/chamber induction
Less potency than isoflurane: This translates into higher vaporizer settings to achieve an
equivalent depth of anesthesia; add 1.8 to your usual isoflurane dial settings for an
approximately equivalent sevoflurane dial setting
Let the patient’s clinical signs dictate the appropriate vaporizer setting

G R O E W
A G
1. With passive scavenging, use independent scavenging systems at each anesthetic work
stations, such that they do not communicate with one another.
2. Passive scavenging is effective if anesthetic machines are free of leaks (see Scavenging
Systems).
3. Minimize the use of face masks and chambers for anesthetic induction or maintenance.
4. Provide scavenging for all induction chambers; operate a countertop fan nearby when
preparing to open an induction chamber to retrieve a patient.
5. Whenever possible, intubate anesthetized patients and maintain ETT cuff inflation. Do not
maintain anesthesia by face mask.
6. Turn vaporizer on only when the patient has been connected to the breathing circuit and the
ETT cuff has been properly inflated.
7. Turn off the flow meter and empty the reservoir bag through the scavenge system whenever
a patient is disconnected from the breathing circuit.
8. Keep an intubated patient connected to the breathing circuit as long as possible after
discontinuing anesthetic gas administration.
9. Recover extubated patients in large, well-ventilated rooms.
10. Correct anesthetic machine and scavenging system leaks promptly.
11. Use keyed vaporizer filling devices.

F B A T O
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Use local/regional anesthesia whenever possible, including epidural morphine or
epidural buprenorphine (unless specifically contraindicated) for all feline patients undergoing hind
end or abdominal surgery (see Lumbosacral Epidural Analgesia).

If the patient is acutely painful prior to anesthesia, incorporate systemic opioid analgesia ±
ketamine into the premedication protocol.

If the patient is persistently hypotensive during inhalant anesthesia, these feline-specific steps can
be taken to raise blood pressure by reducing dependence on inhalant agents for maintenance of
anesthesia:

Add nitrous oxide to the inhalant anesthesia at a ratio of 2:1 nitrous oxide to oxygen
(see Nitrous Oxide Flow Rates)
For mild to moderate intraoperative pain: administer buprenorphine 0.02 mg/kg IV
For moderate intraoperative pain: administer buprenorphine bolus and begin ketamine CRI
For severe pain: fentanyl CRI alone OR combined with ketamine CRI
Nitrous oxide and CRIs can be used together for maximum reduction in inhalant anesthetic
requirements
Regardless of your CRI selection, be on the alert for possible postoperative hyperthermia
If blood pressure does not normalize after implementation of balanced anesthesia technique,
initiate vasopressor therapy. Vasopressor therapy is required more often when the patient is
acutely ill.

C B A T O
Use local/regional anesthesia whenever possible, including epidural morphine or epidural
buprenorphine for all canine patients undergoing hind end or abdominal surgery (see
Lumbosacral Epidural Analgesia).

If the patient is painful prior to anesthesia, administer a pure mu-opioid agonist as a component of
the premedication.

To correct persistent hypotension during inhalant anesthesia, here are some canine-specific steps
that can be taken to raise blood pressure by reducing dependence on inhalant agents for
maintenance of anesthesia:

If intraoperative pain is mild to moderate and/or well controlled with local/regional analgesia,
and only need to reduce reliance on inhalation anesthesia, begin ketamine CRI
For poorly controlled, moderate to severe pain, choose from the following:
Ketamine and morphine CRI
Fentanyl CRI alone OR combined with ketamine CRI
Hydromorphone CRI
If blood pressure does not normalize after implementation of balanced anesthesia technique, I
initiate vasopressor therapy which I rely on most often when the patient is acutely ill.

L -F A
This technique is appropriate for low-flow isoflurane or sevoflurane anesthesia delivered with an
out-of-circle (aka precision) vaporizer.

Use of in-circle (aka non-precision) vaporizers is not recommended

What is low-flow anesthesia?
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The delivery of inhalant anesthesia using reduced oxygen flow rates
What equipment is needed?

A precision vaporizer
A leak-free circle system in excellent working order
An oxygen flow meter which accurately delivers oxygen flows as low as 500 mL/minute
What are the positive features of this technique?

Heat retention by the patient, which may reduce the severity of hypothermia
Cost savings in reduced oxygen and inhalant anesthetic liquid consumption
What changes are noticeable with low-flow anesthesia delivery?

More frequent carbon dioxide absorber granule replacement

Higher vaporizer dial setting requirements
Visible moisture condensation in the expiratory limb of the breathing hoses (not a hazard)
Implementing low-flow anesthesia

See also Monitoring Depth of Anesthesia:

1. At the start of anesthesia, deliver oxygen flow rates at 100–200 mL/kg/minute (maximum 8
liters) for 10 minutes. This flushes room air from the machine and the patient, replaces it
with 100% oxygen, and allows rapid transition to inhalant anesthesia after induction with
injectable drugs. Set the initial vaporizer dial settings according to the patient’s needs based
on signs of anesthesia depth.
2. After 10 minutes, reduce oxygen flow to 20 mL/kg/minute, with a minimum of 500 mL/minute
total flow.
3. If uncomfortable with this low-flow meter setting, select a higher rate, but one that is lower
than usual so as to gradually accustom yourself to low-flow anesthesia delivery.
4. If the patient’s depth of anesthesia is appropriate, raise the vaporizer setting as you
decrease the oxygen flow. If you do not raise the vaporizer setting, the patient’s plane of
anesthesia will lighten.
5. Partially close the exhaust valve to maintain some gas in the reservoir bag in order to use
the reservoir bag movement to assist with monitoring patient ventilation.
6. Make early vaporizer adjustments, up or down, depending on the patient’s clinical signs, as
the response to changes in vaporizer dial settings at this low-flow rate will be slow.
7. If you need to rapidly change the plane of anesthesia, simply return to a high oxygen flow
meter setting and continue until your patient’s anesthetic depth is appropriate; then
decrease the oxygen flow rate once again.
8. Frequently reassess depth of anesthesia.
When should we not use low-flow anesthesia?

1. Do not administer low oxygen flow rates via Bain or other non-rebreathing circuit.
2. Do not administer nitrous oxide under low-flow conditions without an inspiratory oxygen
analyzer.

F T A
Correct dehydration before anesthesia unless faced with an emergency.

Perioperative fluid therapy for healthy well hydrated patients

The 2013 AAHA/AAFP Fluid Therapy Guidelines recommend delivery of 5 mL/kg/hour IV LRS or
equivalent for canine patients and 3 mL/kg/hour for feline patients.
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For my canine outpatients, I deliver a 10 mL/kg rate for the first hour, then reduce the fluid rate to
5 mL/kg/hour, with a therapeutic goal of delivering a total volume of 20 mL/kg over the course of
the hospital stay.

Feline outpatients may benefit from supplemental subcutaneous LRS for a delivered total (IV +
SQ) of at least 100 mL/cat

If you are correcting glucose or electrolyte imbalances intraoperatively, do so with a separate fluid
source delivered independently.

See also What to Do about Hypotension during Maintenance of Inhalant Anesthesia.

If hemorrhage occurs
Administer up to 3–4X estimated lost blood volume as LRS, or equivalent IV, at 20–40 mL/kg/hour
or higher, depending on the rate of blood loss, or if patient is tachycardic and hypotensive.

Anesthesia for the Bleeding Cat/Anesthesia for the Bleeding Dog

Feline/Canine Blood and Colloid Therapy during Anesthesia (see below)
Simultaneous elevated heart rate and low blood pressure may indicate inadequate volume
resuscitation.

Reevaluate the estimated amount of blood lost and replacement fluids, and the possible need for
colloid and/or red blood cells by measuring PCV/TS frequently throughout the perioperative
period.

F B C T A
Blood administration

If PCV approaches 20% and total solids remain above 4 grams %, administer packed RBCs
If PCV approaches 20% and total solids approach 4 grams %, administer whole blood or
packed RBCs and colloid
If treating disseminated intravascular coagulation (DIC), administer fresh whole blood
Always crossmatch feline donors and recipients; typing is not sufficient. Fatal hemolysis can occur
with the transfusion of uncrossmatched blood.

Commercial feline blood products are in limited supply; likely, only fresh whole donor blood will be
available.

Administer through a filter at a rate of 5 mL/kg/hour if patient is stable. Rate can be increased, if
needed, to rapidly replenish circulating blood volume during severe hemorrhage. Allow blood to
mix only with calcium-free solutions, such as Plasmalyte A, normal saline, or Normosol R.

Colloid administration (plasma, dextran, pentastarch or hetastarch)

If PCV is above 20% and total solids declines to 4 grams %, administer plasma sufficient to
raise plasma proteins above 4 grams %
If plasma is not available, administer synthetic colloid
Administration rate

Plasma: Administer over 4–6 hours. Repeat as needed to maintain a plasma solids above 4 g %.

Dextran 70: Administer 5 mL/kg as a bolus. Repeat as needed up to 20 mL/kg to sustain systolic
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Pentastarch or hetastarch: Administer 5 mL/kg over 10–15 minutes. Repeat as needed up to 40
mL/kg to sustain systolic blood pressure above 80 mm Hg or mean blood pressure above 60 mm
Hg.

C B C T A
Blood administration
Transfused blood should be from DEA 1.1 and DEA 7 negative donors; typed and crossmatched
blood is preferred.

Crossmatching is essential for recipients of multiple transfusions.

If PCV acutely approaches 25% and total solids remain above 5 grams %, administer
packed RBCs
If PCV acutely approaches 25% and total solids approach 4 grams %, administer whole
blood or packed RBCs + colloid
If treating disseminated intravascular coagulation (DIC), administer fresh whole blood

Amount of donor blood needed equals:

Administer through a filter at a rate of 5 mL/kg/hour if the patient is stable. The rate can be
increased, if needed, to rapidly replenish circulating blood volume during severe hemorrhage.
Allow blood to mix only with calcium-free solutions, such as Plasmalyte A, normal saline, or
Normosol R.

Colloid administration (plasma, dextran, pentastarch or hetastarch)

If PCV is above 25% and total solids declines to 4 grams %, administer plasma sufficient to
raise plasma proteins above 4 grams %
If plasma is not available, administer synthetic colloid
Administration rate

Plasma: Administer over 4–6 hours. Repeat as needed to maintain TS above 4 g %.

Dextran 70: Administer 5 mL/kg as a bolus over 10–15 minutes. Repeat as needed up to 20
mL/kg to sustain systolic blood pressure above 80 mm Hg or mean blood pressure above 60 mm
Hg.

Pentastarch or hetastarch: Administer 5 mL/kg over 10 to 15 minutes. Repeat as needed up to 20

mL/kg to sustain systolic blood pressure above 80 mm Hg or mean blood pressure above 60 mm
Hg.

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