gassing

Re: gassing

Siobhan Steven — Wed, 20 Feb 2013 10:18:09 GMT

Can you clarify what Premedication he is using? With effective premedication IV catheterisation should be achievable in about 98% of cases and induction should be given through the catheter. A catheter facilitates administration of drugs while a procedure is underway, if he can't find a vein to induce with what would he do if a patient was arresting?

Do you monitor BP/O2 Saturation/ Capnography so you have an idea of the effects of these inductions?

Gassing a patient down should be the absolute last resort for induction, you can make chambers out of perspex aquariums but you need to ensure there is an outlet to scavenge waste gases and a sealed inlet for the isoflurane/sevo O2. The chamber shoud be relative to the patients size, i.e don't have a tiny patient in a large induction box as there is excessive atmospheric pollution when the chamber is opened. And is really only suitable for patients up to approx 7kg.

The effects on the patient includes increased catecholamine release (epinephrine etc) if it struggles, hypotension and increased carbon dioxide concentrations in the blood which increases the risk of potentially fatal cardiac arrhythmias. Induction is prolonged compared to most injectable agents so there is potentially increased chance of the patient experiencing the excitation stage.

If you are 'mask' inducting no matter how well sealed the mask is there will be atmospheric pollution. You can not monitor CRT and MM or eye position easily, and if the patient is prone to regurgitation or vomiting there is a high risk of aspiration. Also gaseous induction should not be performed on brachycephelic patients or those with respiratory disorders.

I'm with those who question why this vet doesn't have the ability to access veins, is he a new grad? (You may have mentioned this and I haven't read it...) i would also be questioning his other practices (I say this obviously being 'removed' from the situation but I have never worked with a practitioner who defaults to gaseous induction as a matter of course).

I would also work out the cost of gas induction vs IV induction with proposal or Alfaxalone, Iso/Sevo & O2 are expensive...and the jury is out on long term effects of regular exposure of volatile agents to people, but I certainly wouldn't be putting my hand up to do them on a regular basis.

I think I have done one mask induction in the past year, and for comparative value I work as an anaesthatist at a Veterinary University.I hope this helps with your discussion.

Re: gassing

Gillian Mostyn — Sun, 17 Feb 2013 21:25:29 GMT

Sounds like a good way of increasing the use of the practice accident book too!

Re: gassing

Selena Carnell — Sun, 17 Feb 2013 20:49:06 GMT

So he is gassing down cats and dogs for routine procedures? Are they pre-med'ed Gassing down wouldn't be the ga of choice, it doesn't really lead to a stable GA if they are fighting prior to being knocked downe. Cats will find it mega stressful having a mask shoved over their face. Have never been in a place that does this routinely, too many gas fumes would be a fire risk too, almost with health issues. Every time I have gassed it has taken twice as long, than getting a vein.

Re: gassing

Shelly vn — Sun, 17 Feb 2013 12:10:58 GMT

Thanks for all your help everyone! He does try very hard and he practises as much as he can but he's very quick to go down the route of gassing the patients. We don't generally catheterise everything but i do encourage it where possible and offer my services to help! The other vet in our practice is also a fan of gassing down, but he's generally better with veins so he doesn't do it as often. But it does make it tricky to talk to him about it. but i'll have a look at some of the links suggested and see what i can do when the health and well being of staff come into it! Thanks for all the advice!

Re: gassing

Gillian Mostyn — Sat, 16 Feb 2013 22:32:23 GMT

[quote user="Shelly vn"]he's not brilliant at hitting veins so his argument is that gassing is less stressful that repeated attempts at i/v induction[/quote]

worrying statement really. Even if masked, it is best to catheterise after induction in case you need emergency IV access. Afterall, if he struggles to hit a vein, he is going to struggle when stressed by an emergency! That could offer some cannulation practice too, when the patient isn't wriggling.

Regardless of that, being able to hit a vein 'off the needle' is a basic skill that a vet needs to have - for seizures and blood sampling at the very least. Do you have another vet at the practice/regional director you could discuss this with? Afterall, if the vet can't hit a vein in an emergency situation there could be a question of neglect/misconduct. Not being able to do something is one matter, not making attempts to train and become proficient is quite another.

Re: gassing

Sophie Bedford RVN CertVNECC — Sat, 16 Feb 2013 12:01:19 GMT

If he's really that bad at getting veins is it worth him looking at triple combo induction? (Dom/Torb/Ket) We use it for our all our small furries and cat castrates but have used it for cat spays in the past before aswell.

Might be worth him going on some training to improve his technique in injections rather than constantly putting staff at risk with gassing down all the time. Would be a nightmare here as we have 2 nurses pregnant!! LOL

Re: gassing

Alison Clare Hickman — Sat, 16 Feb 2013 11:28:25 GMT

RCVS PSS Manual paragraphs 5:10 and 5:11 would apply...

http://www.rcvs.org.uk/document-library/practice-standards-manual/

(You can download the manual)

I believe the laws/principles governing anaesthetic gas safety and monitoring is governed by COSHH (Control of Substances Hazardous to Health) so you could also research under that, for something to show him.

Ali h

ps. Futher ideas - - - If he is so rubbish at hitting veins and worried about stressing the patient, why not encourage him to use EMLA cream before-hand so that the skin is locally anaesthetised and therefore the patient is more likely to tolerate increased handling? What about getting an LVN/RVN who is proficient in iv catheterisation techniques (? you ?) to catheterise first, then he avoids having to use venepuncture himself? ...

I must admit hearing about a qualified vet who is not good at venepuncture and tries to circumnavigate the problem, not by striving to improve his technique but by using a less than desirable solution to overcome his inadequacies, scares me somewhat... what else could he be hiding????

Re: gassing

Sal the 1st — Sat, 16 Feb 2013 10:10:10 GMT

are you using gas monitoring? - you should be getting some 'impressive' results if so - the results from that should be giving you some information, dont know if you will find the below useful or not?

http://www.lovemypet.ie/wp-content/uploads/2012/02/4-Lynne-Hughes-Anaesthetic-Hazards-notes.pdf

Re: gassing

Shelly vn — Sat, 16 Feb 2013 09:38:03 GMT

Thanks Ali, its particularly the health risks to staff i'm interested. i've tried using the argument re patients stress etc, but he's not brilliant at hitting veins so his argument is that gassing is less stressful that repeated attempts at i/v induction. but i'm very concerned about risk to our health and that might be the argument that swings it! Do you know where i might find some info to back this up?

Re: gassing

Alison Clare Hickman — Fri, 15 Feb 2013 15:34:48 GMT

hv u considered arguing the issue of staff health & safety? Exposure to waste gases is considerably higher for gassing down than intubation due to less effective scavenging and gas escaping around masks, no matter how tight the fit....There are recognised long-term health risks with repeated exposure to ansaesthetic gases...

Release of catecholamines in the gassed down patient stressed by the procedure could mean less effective/smooth anaesthetic intra-op and certainly costs more to do since you'd probably need more gas to maintain an effective plane...

Just some ideas to throw into your argument mix!

Ali h

Re: gassing

Shelly vn — Fri, 15 Feb 2013 13:07:10 GMT

Can anyone point me in the direction of any info about the health and safety implications of gassing patients down. We have one vet who has started to do this a lot and is almost going to it as his default method of inducing anaesthesia for all speices. I'm not too happy about this from both the patients point of view and ours and i would like some info to show him!

Re: gassing

Celine — Sat, 26 Jan 2013 13:41:25 GMT

We gas down LOADS of stuff at the zoo, birds and pretty much anything mammalian under about 4kg, as they tend to be too flighty / delicate to crush for a jab, and catching them up for a jab would be so incredibly stressful for them.

This generally involves creating a chamber with a clear plastic bag around their crate - sometimes resulting in quite big chambers and long induction times!

We use sevo if we are going to gas down, as iso is very irritant to mucous membranes, and they taste it more (apparently a lot of people can't smell sevo at all?!? I'm sadly one of the ones who can ) With iso they definitely flip about the cage but sevo is a more gradual induction and they tend to just become wobbly and slowly slump down instead of the iso acrobatics. Obviously if you have a tight-fitting mask you don't have the irritant problem, but still..

I hardly ever used to gas down in practice unless for the circumstances Alison was describing - a chamber is one thing (fine) but pinning down an animal and holding a mask over their face is just asking for them to freak out. Why do you ask? I would say that the animals that are just gassed, with no other drugs, will then require a lot more gas to maintain anaesthesia, but wake-up (especially in the case of sevo) is so rapid (>1 min after turning gas off) that they are up and not wobbly within 10 mins and able to go back with their group under an hour later - very important for us. There's no GA hangover as with injectables.

Hope that helps some.

Re: gassing

Alison Clare Hickman — Sat, 26 Jan 2013 10:36:27 GMT

My answer is: it depends on need and species...

Works well:

a) we routinely gas down rabbits (after a triple pre-med): O2 to start, gradually introduce Isoflurane and then N2O. N2O eases induction and is turned off once a stable plane of anaesthesia is reached (plus we use it at ratio of 1 litre N2O to 2 litre O2...yes, but this is what works - too much N2O can cause problems in a gas filled caecum in the rabbit...).

b) similar procedure for guinea-pigs to rabbits.

c) routinely gas down avian patients.

Personal view, don't like it much (but it does work / needs must):

a) We gas down very small small furries (including hedgehogs) in a chamber. Don't like that much as they roll around and struggle before before they become anaesthetised... As we don't use Sevoflurane at my current practice I don't know if this would make a significant difference to the rolling/struggling problems? Anyone out there who can tell me if this is the case? Suggest a better alternative?

b) Have also non-routinely gassed down other patients for various reasons; such as the cat castrate (induced on propofol) that's regaining a conscious plane before the procedure's fully completed to the emergency patient you cannot immediately intubate.

Hope this is the sort of answer you were after?

Ali h