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Peri-anaesthetic management of the gastric dilation and volvulus (GDV) patient

The emergency presentation of a GDV is often a stressful situation for the veterinary team, and is a scenario were good preparation and an appropriate period for patient stabilisation are vital to a successful outcome. The anaesthetic risk in these cases is particularly high, with most graded on the American Society of Anesthesiologists (ASA) scale as 5(E) on presentation. Appropriate patient stabilisation may reduce this risk to ASA 3(E), and lead to a better patient outcome (please see this article and downloadable chart on Achieving Safer Anaesthesia with ASA). Previous literature has suggested blood lactate at presentation may be a predictor of survival, based on the degree of gastric ischaemia/necrosis, but recent work has shown serial blood lactate measurement to be more useful for guiding treatment and discussing prognosis, rather than a single result.

This brief review will focus on considerations for anaesthesia, analgesia and patient stabilisation following presentation to the clinic.

Considerations

The patient with GDV is very likely to present with multiple clinical derangements that require urgent investigation prior to anaesthesia. These considerations include;

  • Abdominal pain
  • Abdominal/gastric distension
    • Cranial displacement of diaphragm
    • Regurgitation and reflux risk
  • Hypovolaemia/hypovolaemic shock
    • Reduced venous return and cardiac output, arterial hypotension, tachycardia, congested and tacky mucous membranes
  • Cardiac arrhythmias
  • Hypoventilation
    • Panting (increased respiratory rate and reduced tidal volume due to gastric distension and diaphragm displacement)
  • Electrolyte and metabolic disturbances

Pre-anaesthesia preparation

On presentation a full physical examination will provide the clinician with information on patient status and the degree of cardiovascular compromise present. Particular attention should be paid to examination of the cardiovascular system, including heart/pulse rate, arterial blood pressure and electrocardiography (ECG) and the gastrointestinal system. During placement of intravenous access blood may be drawn for biochemical and haematological analysis, including electrolytes and where possible lactate and blood gases.

Analgesia should be provided following baseline patient data collection. A full mu agonist opioid, such as methadone is most appropriate for administration at this time, may be given IV and has a quick onset time.  

Patient stabilisation should continue with administration of fluid therapy, Hartmanns/ Lactated Ringers solution is an appropriate selection (see fluid therapy section for further details). Regular monitoring of the cardiovascular system should be performed to assess patient response to fluid therapy.  Following analgesia administration and during initial fluid therapy, further diagnostics may be possible, including abdominal radiography to confirm GD or GDV, followed by gastric decompression. Orogastric intubation may be possible in certain patients, otherwise percutaneous decompression may be performed. Gastric decompression is an important procedure to reduce the risk of cardiovascular collapse during induction of anaesthesia. Continuous monitoring of ECG is useful to detect the presence of any ventricular arrhythmias that are common with this disease presentation. Recent evidence has suggested that the early use of a lidocaine IV bolus followed by infusion (2mg/kg followed by 50mcg/kg/min) is beneficial, in terms of reduced occurrence of cardiac arrhythmias, risk of acute kidney injury and hospitalisation time. Commencement of a lidocaine infusion may therefore be considered following initial triage and should be continued throughout the peri-operative period. Close monitoring should be paid for any early signs of toxicity, including nausea and tremors.

Blood work

Pre-anaesthetic blood work should be used to further assess patient status, focusing on the incidence of haemoconcentration (PCV and TS), acid-base status (such as evidence of acidaemia), hyperlactataemia and other indicators of reduced tissue perfusion, electrolyte abnormalities that may require correction and indicators of organ dysfunction, e.g. acute kidney injury, using markers such as creatinine and BUN.

Fluid therapy and cardiovascular support

Crystalloid fluid therapy should form the basis of initial resuscitative efforts. The aim being to restore circulating volume, tissue perfusion and oxygen delivery. Volume requirements should be based on patient response to fluid resuscitation. Bolus dosing should be based on 10-20ml/kg aliquots administered over 10-20 minutes, followed by patient reassessment. A positive response should indicate the patient is fluid responsive, and a further bolus should therefore be administered. If no further response is noted, then this may indicate that vasopressor administration is required. Noradrenaline is likely to be the most appropriate vasopressor to select at this time. It should be titrated to effect, has a rapid onset and following discontinuation a rapid termination of effect. Small, incremental dose increases are recommended to avoid significant vasoconstriction which may result in profound vasoconstriction and a significant bradycardia/bradyarrhythmia. Restoration of a more normal heart rate and adequate arterial blood pressure are indicators that volume and vessel tone are more normal and the patient is more stable to proceed to induction of anaesthesia.

Protocol selection

Anaesthesia agent selection should be based on those most appropriate for the patient, but also those most familiar to the clinician. As already eluded to, induction of anaesthesia should be postponed until the patient’s cardiovascular status is considered stable enough to manage the stress associated with it. 

Further PREMEDICATION may not be required in addition to the earlier administered of methadone in the compromised patient. 

INDUCTION of anaesthesia should be achieved with an IV agent. Alfaxalone is an excellent choice in this clinical scenario, with evidence in the literature to support its safety profile and use. In a 2011 study it was shown to be a suitable alternative when compared to a potent opioid and benzodiazepine combination for induction of anaesthesia in sick dogs (ASA 3-5) (please see this summary of the 2011 article by Psatha et al examining the use of alfaxalone in high risk patients). The use of a co-induction protocol with a benzodiazepine may allow for a reduction in the dose required of the IV induction agent and also improve conditions associated with tracheal intubation. The cardiorespiratory depressant effects of the IV induction agents are dose related and therefore can be minimised if the agent is injected slowly to allow for sufficient circulation time for its full effect (please see the Alfaxan User Guide). Care should be exercised to minimise the risk of regurgitation of gastric contents, therefore ensuring the airway is secured prior to allowing the head to be placed below the level of the abdomen. 

MAINTENANCE of anaesthesia using an inhalational agent (isoflurane or sevoflurane) is most common allowing the appropriate adjustment of vaporiser setting according to depth of anaesthesia. The main adverse effects observed with the inhalational agents are respiratory depression and vasodilation, resulting in hypoventilation and hypotension, both of which are dose dependent (see intra-operative analgesia below). Significant hypoventilation, resulting in hypercapnia (end-tidal CO2 values greater than 55-60mmHg) will require implementation of supportive ventilation, either intermittent manual ventilation or positive pressure ventilation, if available.

Intra-operative analgesia

Good provision of intra-operative analgesia is essential, with the aim to reduce inhalational anaesthesia requirements and therefore adverse effects such as vasodilation and hypoventilation. Non-steroidal anti-inflammatory drugs (NSAIDS) should be avoided until the patient is considered stable and recovering well in the post-operative period. Options for analgesia during laparotomy for GDV correction include:

  • Opioid analgesia
    • Bolus dosing of e.g. methadone (0.1-0.2mg/kg) or fentanyl (1-2mcg/kg)
    • Continuous infusion of e.g. fentanyl (5-10mcg/kg/hr)
  • Lidocaine
    • This may be continued during the peri-anaesthesia period (25-50mcg/kg/min)
  • Paracetamol (acetaminophen)
    • 10mg/kg IV q8-12 hours
  • Ketamine
    • Continuous infusion following a loading dose (0.2mg/kg IV bolus; 5-10mcg/kg/min)
  • Epidural anaesthesia
    • May be considered but caution is advised, particularly in the patient with signs consistent with sepsis or septic shock

Monitoring during anaesthesia

Continuous monitoring of patient status is an important aspect of patient safety during any anaesthetic. The use of multiple modalities of monitoring equipment will be extremely useful during anaesthesia and should focus on the considerations discussed. Monitoring of arterial blood pressure, pulse oximetry, ECG, body temperature and capnography and ETCO2 will provide invaluable information to ensure appropriate provision of analgesia, fluid therapy and depth of anaesthesia. If invasive blood pressure monitoring is available this will provide further information, allowing assessment of real time changes, as well as for blood gas sampling. Please see: The Big Chill; Nuances of CV Monitoring; Capnography I; and Capnography II for additional information.

Patient monitoring during anaesthesia should be focused on:

Fluid therapy

Current recommendations suggest an initial rate of 4-5ml/kg/h in healthy dogs during anaesthesia, tailored to the individual. The patient with GDV is definitely a case where additional fluid therapy is required, and initial crystalloid rates during anaesthesia are more likely to be around 10ml/kg/h, allowing then for adjustment as needed. Although the use of colloids has reduced in recent years, there are likely to be situations, particularly with large breed dogs or those non-septic patients that are non-responsive to crystalloid therapy where colloids may be considered. Both vasopressor and inotropic support may be required during anaesthesia to maintain vascular tone and cardiac contractility.

Recovery

The recovery period is just as important as any other part of anaesthesia. Careful monitoring should aim to address a number of points:

  • Continuous monitoring until the patient has their trachea extubated and can maintain sternal recumbency
  • Regular monitoring until body temperature is over 37oC
  • Monitoring of ECG and arterial blood pressure are useful to detect any arrhythmias, and any subsequent effect on arterial blood pressure
  • The bladder should be checked before the patient regains consciousness and emptied if required
  • Pain should be assessed on a regular basis and analgesia provided as required. Methadone as required is likely to form the back bone of post-operative analgesia, along with continuation of a lidocaine infusion and the use of IV paracetamol (please see Practical Acute Pain Assessment).
  • Fluid therapy should be continued with an appropriate type and rate dependent on patient status
  • Continued monitoring of biochemical status may be indicated, to ensure normality of acid-base status, electrolytes and to assess any organ dysfunction
  • Continuation of vasopressor support may be indicated in the early recovery phase
  • Nutritional status should be carefully assessed

Summary

Careful physical examination, identification of patient factors and consideration of anaesthetic risks will ensure good patient safety. Good preparation and planning, prior to induction of anaesthesia are key to a successful outcome in the patient with GDV.

Article by
Carl Bradbrook
BVSc CertVA DipECVAA MRCVS.

RCVS and EBVS® European Specialist in Veterinary Anaesthesia and Analgesia

Carl graduated from the University of Liverpool in 2002 and after a few years in mixed practice undertook a residency in anaesthesia and intensive care at The Royal Veterinary College. He has worked in both private and university specialist centres and most recently worked as an independent anaesthesia consultant.

Carl is an RCVS Recognised Specialist and a European Veterinary Specialist and is currently President of the Association of Veterinary Anaesthetists. Carl joined Anderson Moores Veterinary Specialists in October 2018. His main areas of interest are the use of regional local anaesthetic techniques, monitoring of ventilation and neuroanaesthesia.

Carl recently contributed to a chapter on ophthalmic pain in the BSAVA Guide to Pain Management and published a review on acute pain management in The Veterinary Journal.

Originally published: Tuesday, 15th October 2019

References

Further reading

Bruchim, Y., Itay, S., Shira, B.-H., Kelmer, E., Sigal, Y., Itamar, A., & Gilad, S. (2012). Evaluation of lidocaine treatment on frequency of cardiac arrhythmias, acute kidney injury, and hospitalization time in dogs with gastric dilatation volvulus. Journal of Veterinary Emergency and Critical Care, 22(4), 419–427.

Green, T. I., Tonozzi, C. C., Kirby, R., & Rudloff, E. (2011). Evaluation of initial plasma lactate values as a predictor of gastric necrosis and initial and subsequent plasma lactate values as a predictor of survival in dogs with gastric dilatation-volvulus: 84 dogs (2003-2007). Journal of Veterinary Emergency and Critical Care, 21(1), 36–44.

Psatha, E., Alibhai, H.I.K., Jimenez-Lozano, A., Armitage-Chan, E., & Brodbelt, D.C. (2011). Clinical efficacy and cardiorespiratory effects of Alfaxalone, or diazepam/fentanyl for induction of anaesthesia in dogs that are a poor anaesthetic risk. Veterinary Anaesthesia and Analgesia, 38, 24-36.


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