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Anaesthesia for Canine Cushing's disease: What should we assess and what should we monitor?

CANINE CUSHING'S DISEASE: PRE-ANAESTHETIC ASSESSMENT AND MONITORING.

PRE-ANAESTHETIC ASSESSMENT

Prior to any anaesthetic every patient, regardless of procedure, should be evaluated via signalment, acquiring a detailed medical history and performing a thorough physical examination. Appropriate diagnostic procedures should be performed, and an American Society of Anaesthesiologists (ASA) physical status score allocated.

Signalment

Species, breed, age and gender (signalment) can identify disease predispositions and potential anaesthetic complications, permitting appropriate preparation to be made. Dogs are more likely than cats to develop hyperadrenocorticism (HAC; Cushing’s disease) and middle-aged/geriatric patients (Dodman et al., 1984, defines geriatric as completion of 70-80% of predicted life-expectancy) are more likely to have concurrent diseases and reduced organ reserve than younger counterparts (Joubert, 2007). Advancing age reduces thermoregulation; hepatic and renal function; cardiovascular reserve and cardiac output (CO); thoracic cage compliance and lung elasticity; brain size; and reflexes. These physiological changes should be considered when selecting anaesthetic and monitoring protocols for the geriatric patients particularly when compounded by concurrent HAC (Hughes, 2008).

Clinical history

A detailed medical history should be obtained, ideally using a standard format to ensure key factors are not overlooked (Duncan, 2009). Basic information includes: vaccination and worming history; recent or current illnesses (including allergies) and current medications. Behaviour, exercise tolerance, episodes of syncope, respiratory difficulties, coughing and sneezing should be assessed to provide information on cardiorespiratory function (Posner 2016; Haggstrom, 2018). Appetite, thirst, weight change, urine and faecal output can all be affected by both HAC and ageing. Polydipsia and polyuria (PU/PD) indicate the maintenance of hydration and blood pressure will be essential during anaesthesia. Integument changes e.g. thinning, infections, and hair loss, may occur with HAC. Previous anaesthetics (and complications) should also be noted and the time of the patient’s last meal.

Clinical examination

Physical examination should follow a standard format to ensure all body systems have been assessed (Duncan, 2009; Posner, 2016): Temperature, pulse and respiratory rates should be observed plus examination of mentation/behaviour (central nervous system); respiratory and cardiovascular function; gastrointestinal and urinary systems; hydration; and integument. Body condition score will assess the degree of obesity. Obesity can negatively affect cardiorespiratory function, particularly when combined with HAC induced hepatomegaly and cranially located abdominal fat. The enlarged abdomen compromises diaphragmatic movement (Walsh, 2016) and reduces the functional residual capacity of lungs which also have suboptimal elasticity. Weak respiratory muscles (Walsh, 2016), calcification of airways (Lunn, n.d.), reduced pulmonary compliance, pulmonary hypertension and possible pulmonary thromboembolism (Kintzer & Peterson, 2006; Mama, 2012; Walsh, 2016) and/or pulmonary metastases (Pacini et al., 2017) increase the risk of hypoventilation and hypoxaemia (Posner, 2016).

Respiratory rate and character can be evaluated by observation and auscultation. Heart rate and rhythm, peripheral pulse rate and synchronicity/quality, mucous membrane colour and capillary refill time should also be evaluated (Duncan, 2009).  Hydration status should be appraised as PU/PD is likely to result in hypovolaemia and electrolyte abnormalities although skin tenting/elasticity may be difficult to determine with HAC due to skin thinning (Posner, 2016). The skin of HAC patients is prone bruising, pyoderma, calcinosis cutis (Lunn, n.d.) and delayed healing, which may be an issue with intravenous or intra-arterial cannulation, epidural anaesthesia, and following surgery.

HAC (and advancing age) necessitate further investigation of blood pressure and arterial oxygen saturation. Thoracic/abdominal imaging, urinalysis and laboratory diagnostics, and other examinations as necessary e.g. ECG, should also be performed prior to anaesthesia to determine the physical condition of the patient and provide baselines for intra- and post-anaesthetic monitoring.  

Blood pressure

Over 50% HAC patients demonstrate hypertension therefore pre-anaesthetic BP should be appraised and the patient stabilised if indicated. Either Doppler, which assesses systolic arterial pressure (SAP) in the dog, or oscillometric (assessing mean arterial pressure - MAP) techniques may be used (da Cunha & Johnson, 2018).

Pulse oximetry

Evaluation of arterial haemoglobin oxygen saturation via pulse-oximetry will indicate the efficiency of blood oxygenation, degree of peripheral perfusion, and a pulse rate (Grint, 2007). However, pulse oximetry does not measure ventilation efficiency, this requires assessment of end-tidal carbon dioxide (ETCO2) via capnography (see later). 

Imaging

Imaging (radiography/CT/MRI) of the thorax and abdomen should be performed (if not already completed) to detect calcified airways and/or soft tissues, pulmonary thromboembolism and/or metastases and the degree of hepatomegaly.

Laboratory analysis

A “stress leukogram” with mild erythrocytosis is typical of HAC and biochemistry generally demonstrates increased cholesterol, ALT, SAP, and a slightly reduced sodium and potassium (Lunn, n.d.). Approximately 10% of HAC dogs have diabetes mellitus (Kintzer & Peterson, 2006) and this should be stabilised (if possible) prior to, and monitored throughout, anaesthesia and into recovery. 

ASA Physical Status Category

Following all pre-anaesthetic assessments an  ASA physical status category should be assigned. Broadbelt (2008) calculated the peri-anaesthetic death rate in healthy (ASA I-II) dogs to be 1:1849 but for ASA III-V patients the risk was 1:75 with inadequate monitoring and hypothermia the most important causal factors. See “Achieving Safer Anaesthesia with ASA”


ANAESTHETIC MONITORING

Blood pressure

Monitoring of blood pressure (BP) is essential in HAC patients: The “stress response” to high levels of circulating glucocorticoids causes hypertension in over 50% of dogs (Lunn, n.d.) and if cardiac reserve is limited, as may be the case in geriatric patients, hypoxia and cardiac arrhythmias can occur reducing the perfusion of vital organs (Carr, 2004; Guyton, 1996). Positioning in dorsal recumbency e.g. for ventral mid-line laparotomy, can compress the caudal vena cava and aorta potentially reducing venous return and CO, therefore leading to hypotension. The most commonly used intra-anaesthetic BP assessment method in veterinary patients is the oscillometric technique. It is simple and automated providing reliable, regular, MAP readings. Assessment of BP via Doppler is just as suitable, although more time consuming, and provides systolic blood pressure results in the dog. Regardless of which technique is selected, care must be taken selecting the correct cuff width (40% circumference of the application site) to avoid under- or over-measurement of BP. See “Keeping a finger on the pulse”.

Pulse oximetry and capnography

Easily fatigued atrophied muscles (observed with both HAC and advancing age) combined with reduced lung elasticity and a less compliant thoracic cage, cortisol effects on the respiratory centre (seen in HAC), cranial abdominal fat, hepatomegaly and a distended abdomen are commonly observed in HAC. When combined with supine positioning during surgery the increased pressure on the diaphragm reduces its ability to flatten and can result in hypoventilation (exacerbated by volatile agents) (Kintzer & Peterson, 2006), hypoxaemia and hypercapnia (Walsh, 2016). This  increases the risk of cardiac arrhythmias (Hughes, 2008).  Hence, monitoring of ventilation and gas exchange via pulse oximetry and capnography is essential. 

Pulse oximetry requires efficient gas exchange in the alveoli and adequate peripheral blood flow to provide a measurement of haemoglobin oxygen saturation (SpO2) and can identify hypoventilation (common in HAC patients) more rapidly than clinical signs such as cyanosis.  Provided it does not increase patient stress, preoxygenation for at least 3 minutes prior to anaesthetic induction will be invaluable.  See “Preoxygenation Study Highlights”.

Capnography is the non-invasive assessment of respired carbon dioxide (CO2) depicted as a capnogram with a numerical value for expired CO2 (end tidal CO2 – ETCO2) and directly or indirectly provides simultaneous information on: metabolism (Simpson, 2014; Smallhout, 2010); CO; adequacy of ventilation; rebreathing; V/Q (ventilation/perfusion) mismatching; and equipment errors e.g. endotracheal obstruction, exhausted carbon dioxide absorber.  ETCO2 should fall within the range 35-45mmHg. See “Capnography” and “Capnography II”.

Temperature

Temperature must be monitored and maintained. A 1oC fall in core temperature can reduce metabolic rate by 10% and increase recovery times (Pottie et al., 2007). With hypothermia minimal alveolar concentrations of volatiles are reduced, less drug is required to induce/maintain anaesthesia and excessive anaesthetic depth & cardiorespiratory depression may occur. Shivering can increase myocardial oxygen demand (Mohta et al., 2009; Self 2015) and this is of great concern in HAC patients with wasted, easily fatigued, respiratory muscles. Immune function is impaired with both HAC and hypothermia leading  to increased surgical site infections. See “The Big Chill”.

ECG

A 3-lead (minimum) ECG should ideally be employed to monitor heart rate and for arrhythmias during the peri-anaesthetic period although it should be complemented with all of the above monitoring techniques as ECG only measures electrical activity, not cardiac function. (Clark, 2009). See “Keeping a finger on the pulse”.

Blood glucose

HAC patients with known, or a pre-anaesthetic diagnosis of, diabetes mellitus  should be stabilised and monitored throughout anaesthesia (Kintzer & Peterson, 2006).  Hypoglycaemia can delay recovery and should be considered even in patients without diagnosed diabetes mellitus.

Urine output

The PD/PU associated with HAC results in excessive urine production which may be exacerbated by fluid therapy during the peri-anaesthetic period.  An indwelling urinary catheter will permit the assessment of urine production, provide samples for urinalysis and will negate the need to regularly express the bladder.  A full bladder can result in excitable recoveries.

SUMMARY

In 2009 the updated guidelines from the American College of Veterinary Anaesthesia and Analgesia recommended anaesthetic monitoring of circulation, oxygenation, ventilation, temperature (and neuromuscular blockade). Therefore, pre-anaesthetic assessment of the HAC patient should include signalment, a detailed medical history and a thorough physical examination. Additional investigations include blood pressure and arterial oxygen saturation, thoracic/abdominal imaging, ECG, urinalysis and blood/biochemical analysis.  Anaesthetic monitoring, which must be continued into recovery wherever possible, is based on a thorough and continuous clinical assessment and capnography, pulse oximetry, temperature, blood glucose and urine output assessment are essential, together with ECG.

 

Click here for your downloadable summary of Cushing’s disease: preanaesthetic assessment and monitoring.

Article by
Dr. Karen Heskin
BVSc CertSAO MRCVS

Veterinary Technical Manager, Jurox UK

Originally published: Thursday, 23rd May 2019
Last updated: Friday, 31st May 2019

References

American College of Veterinary Anesthesia and Analgesia Small Animal Monitoring Guidelines. Available from: http://acvaa.org.

Broadbelt D.C., Blissett K.J., Hammond R.A., Neath P.J., Young L.E., Pfeiffer D.U. and Wood J.L.N. (2008). The risk of death: The Confidential Enquiry into Perioperative Small Animal Fatalities. Vet Anaesth Analg. 35: 365-373

Carr A.P., (2004). Cardiac disease in geriatric dogs and cats. In: Geriatrics and Gerontology of the Dog and Cat. 2nd ed. Hoskins J. D. (ed) Saunders. St. Louis.

Clark L. (2009). Monitoring the Anaesthetised Patient. In: Anaesthesia for Veterinary Nurses. 2nd ed. Welsh L. (ed). Wiley-Blackwell.

Da Cunha A.F. and Johnson R.A. (2018). Cardiovascular monitoring. In: Veterinary Anaesthetic and Monitoring Equipment. Cooley K. G. and Johnson R. A. (eds). Wiley & Sons.

Dodman N.H., Seeler D.C and Court M.H. (1984). Ageing changes in the geriatric dog and their impact on anaesthesia. Compendium on Continuing Education for the Practicing Veterinarian. 6: 1106-1113

Duncan J. (2009) Preoperative Assessment and Preparation of the Patient. In: Anaesthesia for Veterinary Nurses. 2nd ed. Welsh L. (ed). Wiley-Blackwell.

Grint N. (2007). Pulse oximetry. Vet Nursing Journal. 22: 20-23

Guyton A., and Hall J. (1996). Textbook of Medical Physiology. 9th ed. Saunders. Pennsylvania

Haggstrom J. (2018). Myxomatous mitral valve disease. In: BSAVA Manual of Canine and Feline Cardiorespiratory Medicine. 2nd ed. Luis Fuentes V., Johnson L.R and Dennis S. (eds). BSAVA, Gloucester.

Hughes J.M.L. (2008). Anaesthesia for the geriatric dog and cat. Irish Vet J. 61(6): 380-387

Kintzer P.P. and Peterson M.E. (2006). Diseases of the adrenal gland. In: Saunders Manual of Small Animal Practice. Birchard S.J. and Sherding R.G. (eds). Elsevier, St Louis.

Joubert K.E. (2007). Pre-anaesthetic screening of geriatric dogs. J S Afr Vet Ass. 78(1): 31-35

Lunn K.F. (n.d.). Canine hyperadrenocorticism (HAC; Cushing’s Syndrome). North Carolina State College of Veterinary Medicine.

Mama K. (2012). Anesthesia for adrenal gland disease. Clinician’s Brief. 97-99

Mohta M,. Kumari N., Tyagi A., Sethi A.K., Agarwal D. and Singh M. (2009). Tramadol for prevention of post-anaesthetic shivering: a randomised double-blind comparison with pethidine. Anaesthesia. 64: 141-146

Pacini T., Jerico M.M., Scalize L.P. and Nishiya A.T. (2017). Adrenalectomy in dogs: retrospective study of 13 cases performed in Universidade Anhembri Morumbi Veterinary Hospital (2012-2015). Braz J Vet Res Anim Sci. 54: 342-349

Posner L.P. (2016). Pre-anaesthetic assessment and preparation. In: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 3rd ed. Duke-Novakovski T., de Vries M and Seymour C (eds). BSAVA, Gloucester.

Pottie R.G., Dart C.M., Perkins N.R. and Hodgson D.R. (2007). Effect of hypothermia on recovery from general anaesthesia in the dog. Aust Vet J. 85: 158-162

Self I. (2015). Practical aspects of anaesthetic monitoring, part2: respiratory system and temperature monitoring. Companion Animal. 20(12): 657-661

Simpson K. (2014). Capnography for veterinary nurses – Part 1: The basics. Veterinary Nursing Journal. 29: 358-361

Smallhout B. (2010). Capnography Handbook. Respiratory Critical Care. CareFusion, Yorba Linda, California.

Walsh K. (2016). Anaesthesia for patients with endocrine disease. Vet Times.

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