Reptile Anesthesia and Analgesia

David L. McRuer M.Sc., D.V.M., D.V.M., Dipl. ACVPM Wildlife Center of Virginia December 5 2006 5,

Metabolism and Thermoregulation

Reptilian resting metabolic rate (MR) is 1/10th to 1/3rd that of mammals of equivalent size Minimum and maximum O2 consumption rates range from nearly 0 to that of mammals y A decrease in the cellular MR can result in reduction of drug metabolism and th f d t b li d therefore i increases i d in drug l t latency of onset, duration of effect, and time of recovery

Metabolism and Thermoregulation

Ambient temperature is one of the main determinants of MR p Temp O2 demand from tissues in metabolic capacity of various organ systems Species variation in MR both between and within taxa p Metabolic rate can increase 3-40 times after a meal and 3remain elevated for up to 7 days days. It is unclear whether this has any effect on reptile anesthesia

Metabolism and Thermoregulation

In general: g
Varanid and lacertid lizards have high MR Boid snakes and chelonians have lower MR Surface dwelling squamates (snakes and lizards) have higher MR than burrowing species Lizards that eat insects or other vertebrates have higher MR than herbivores

Metabolism and Thermoregulation

Reptiles are ectotherms gaining heat from environment p g g
In warm conditions reptiles can increase HR and increase the degree of left-to-right shunting to send more blood to the left-top p y periphery to be warmed thus ultimately increasing core body y g y temp.

Large pythons and leatherback sea turtles are large enough to produce their own heat through muscle movement

Metabolism and Thermoregulation

Normal body temp is referred to as Preferred Optimal Temperature Zone (POTZ) or Preferred Body Temperature T t Z P f dB d T t (PBT) or Internal Thermal Set Point. Maintained by basking and alternating between sun and shade HypoxiaHypoxia-induced hyperthermia/hypothermia:
At temperature extremes, a mismatch exists between O2 demand and O2 supply leading to hypoxia. In the hypoxic state aerobic metabolism is decreased as are state, other activities such as dive times.

hydration decreases PBT y

Cardiovascular system and Anesthesia

Intracardiac shunting of blood occurs in the g noncrocodilian reptile ventricle This serves 3 functions:
1) 2) Stabilizes O2 content of the blood during respiratory pauses Right-toRight-to-left shunt is partly responsible for an increase in systemic blood flow that facilitates the maintenance of body temperature. Right-toRight-to-left shunt directs blood away from lungs during diving

3)

Cardiovascular system and Anesthesia

Implications for anesthesia:
Shunting is controlled by cholinergic and adrenergic factors Can effect the systemic arterial O2 content and uptake and elimination of inhaled gases g
Large right-to-left shunts limit right-tog p y amount of gas uptake early in anesthesia and slow anesthetic elimination during the end of anesthesia Changes in level and direction of shunting can account for unrepentant awakening during surgery

Cardiovascular system and Anesthesia

Blood pressure controlled similar to mammals p Systemic arterial blood pressures vary considerably in reptiles depending on species. BP is affected by environmental stresses (temperature and habitat), activity levels, and size of the reptile.

Respiratory System and Anesthesia

Lower O2 consumption rate than mammals p Large tidal volume but small surface area for gas exchange No diaphragm therefore active inspiration and expiration Many muscles that control ventilation are also responsible for locomotion incompatible while under anesthesia

Effects of Inspired CO2 and O2

Variable across species p More than 4% CO2 causes an in tidal volume and a in resp frequency and minute ventilation Turtles: breathing between 10-21% O2 does not change 10resp pattern. High concentrations of O2 can decrease resp. rate. Therefore some studies have shown it is faster to recover reptiles on room air. til i

Hepatic System and Anesthesia

Liver has a slower MR than mammals and may account y for the prolonged excretion of drugs (including some anesthetic drugs) from the body.

Drug Administration Routes

IM injection
First pass effect in kidneys from rear limb injection is more theoretical than a practical concern concern. However, still best to avoid nephrotoxic drugs and drugs mainly metabolized by the kidneys when giving rear limb injections Snakes epaxial muscle Lizards forelimb, hindlimb, and tail
Caution: some animals can autotomize their tails

Chelonians: triceps
Caution: avoid cranial surface of forelimb radial nerve

Drug Administration Routes

IV administration
Snakes & lizards ventral coccygeal vein Freshwater turtles & tortoises dorsal coccygeal vein Sea turtles: Dorsal Cervical Sinus

IV injections decrease the variability compared to IM injections in reptiles

Drug Administration Routes

IO catheterization
Best suited for lizards Placed in femur or tibia Renal uptake of radioactive substances is the same whether given IV or IO

Premedication
General purpose of premeds: : - t facilitate handling, to f ilit t h dli catheterization, reduce handling stress, and reduce g , side effects caused by higher doses of induction and maintenance drugs Depending on the p p g premed drug(s), you may or may not produce sedation or decrease induction or maintenance drugs therefore choose according to your goals.

Premedication
Anticholinergics g
Ex: atropine, glycopyrrolate Increase salivary viscosity predisposing patient to endotracheal tube obstruction Can alter intra-cardiac shunt fractions thereby altering response intrato inhaled anesthetics.

Premedication
Phenothiazines
Ex: acepromazine Only effective in reptiles at very high doses and have prolonged effects not often used

Premedication
Phencylidine y
Ex: ketamine, telazol ketamine,

Ketamine K t i
At subanesthetic levels, it produces analgesic effects and sedation Animals are in a cataleptic state marked by uncoordinated voluntary and involuntary muscle movements Ketamine does NOT PRODUCE A SURGICAL PLANE by itself Often combined with benzodiazepines or 2-antagonists to produce muscle relaxation

Premedication
Phencylidine y Telazol (tiletamine and zolazepam) zolazepam)
Produces variable results in reptiles Less desirable than Ketamine and midazolam due to the longer duration of effect and longer recoveries. Occasionally used in large lizards to reduce the injectable volume

Premedication
Benzodiazepine
Ex: midazolam, diazepam midazolam, p

Diazepam
Not to be used IM as absorption is very poor

Midazolam
Often used in conjunction with ketamine for sedation and induction of anesthesia in chelonians (turtles) Does not provide significant sedation when used alone in snapping turtles and painted turtles.

Premedication
-antagonists g
provide sedation and muscle relaxation Clinical impressions suggest some degree of analgesia although not yet tested in reptiles Medetomidine has a higher 2:1 binding ratio than xylazine and produces better anesthetic depth for intubations. Ketamine combination will reduce the risk of HR, Resp rate, CO, HR rate CO ventricular pressures, Can be reversed with atipamazole given IM (not IV hypotension)

Premedication
Opioids p
Poor sedatives in reptiles Commonly used for analgesia although few studies in reptiles.

Induction of Anesthesia
Propofol (drug of choice if IV catheter is present) can be used IO however has been associated with apnea in green iguanas Induction with gas anesthesia varies g due to breath holding.
Stroking the lateral thorax may promote breath taking

Mean induction time on isoflurane is 20 min. Muscle relaxants (succinylcholine & (succinylcholine atracurium) atracurium) work well for immobilization but have no analgesic or amnesic properties avoid regular use in anesthesia

Endotracheal Intubation
Easily visualized in most reptiles y p Rostral in snakes, behind the tongue in lizards and chelonians Complete tracheal rings in chelonians and crocidilians, crocidilians, therefore use uncuffed endotracheal tubes Thick mucous in retiles can plug ET tubes t b Rostral bifurcation of trachea in chelonians watch for single lung intubation

Maintenance
MAC
Isoflurane reptiles range = 1.54% 3.14% Sevoflurane (Dumerils monitor) = 2.51% Dumeril s 2 51% 0.5% MAC values can vary based on technique used to measure body temperature measure, temperature, species differences, and right-to-left right-tointracardiac shunting Right-to-left shunting directs blood away Right-tofrom the lungs therefore less gas can be absorbed. Reptiles can be episodic breathers

Isoflurane
DoseDose-dependant cardiovascular depression MAY occur in reptiles A dose-dependant sevoflurane study with desert dosetortoises did not show a decrease in ventricular blood pressure or heart rate rate. 4X MAC with isoflurane in green iguanas does not induce cardiovascular arrest.

Equipment
O2 rate = 50-100 ml/kg/min for rebreathing system 50g g y O2 rate = 200-300 ml/kg/min for Bain system 200For most vaporizers 200ml/min is required for vaporizer accuracy. Ventilators = often necessary use one designed for small animals animals.

Monitoring
Reflexes:
When induced with inhalent anesthesia, muscle relaxation starts at midbody, then cranially, then caudally. Tail tone is lost last Corneal reflex should still be present (not in snakes and some lizards due to the spectacle).

Monitoring
Cardiovascular:
Small bell stethoscope on wet gauze placed on the animal Esophageal stethoscope advanced slowing to the point of maximum intensity. intensity Ultrasonic Doppler device with a pediatric probe The Doppler can also be used for measuring changes in blood pressure

ECG
ECG measures heart rate and rhythm. Reptiles have y p an SV wave proceeding the P wave. Lizards place left and right forelimb leads on cervical region t increase signal strength i to i i l t th Snakes
heart located 20%-25% of length from the head 20% Place leads two heart lengths in front of and behind the heart

Chelonians
Leads placed on the skin between neck and forelimbs.

Attaching leads to needles or a stainless steel loop may increase signal strength.

Respiratory Monitoring
Reptiles do not breath well on their own under p anesthesia Recommendation:
Mechanical ventilation at 2-6 breaths/min, 15-30 ml/kg tidal 215volume, peak airway pressure less than 10 cm H2O

Only one study has shown a relationship between y y p hemoglobin saturation from pulse oximetry and arterial hemoglobin saturation (green iguanas). Other studies have failed to show this relationship

Respiratory Monitoring
Capnometry: Capnometry: difficult to interpret in reptiles due to rightp y p p rightg toto-left intracardiac shunting Blood gas analysis:
Effected by: site of sampling, arterial vs venus blood, species, inspired O2 concentration, thermoregulatory status, ventilatory p g y y status of patient Reptiles tend to have lower body temp. than mammals causing their blood pH to be higher. g PO2 and PCO2 tend to be lower than mammals

Fluid Therapy
Best to rehydrate before anesthesia y IV or IO is best however, IP and SQ may be used Reptiles have a higher % of there body water in the intracellular space compared to mammals

Thermal Support
Best to keep animals in the hospital at the upper range p p pp g of the POTZ. At lower environmental temperatures, you can see prolonged d l d drug effects, i ff t impaired i i d immune status and rate t t d t of healing

Analgesia
Preemptive analgesia: central sensitization, facilitate healing, prevent detrimental neurohumeral response to pain, amount of maintenance drugs during anesthesia Neuroanatomy consists of endogenous antinociceptive mechanisms, demonstrable modulation of pain by drugs, neural tract in the brain and spinal cord that suggest a means of mediating descending inhibition of nociception. Opioid receptors are found in reptiles and involved with p p p reproduction and thermoregulation. Little known about the role of opiods in nociception nociception.

Analgesia
Important to know normal species behaviors to know p p what behaviors may be interpreted as pain or stress. Three main classes of analgesic drugs:
1) 2) 3) Local anesthetics NSAIDS Opioids

Analgesia Locals
Interupt nociception from the level of the nociceptor to p p p the spinal cord. Pay special attention to toxic dose as you are often working with small patients. ki ith ll ti t Lidocaine and Bupivicaine (longer-lasting 1-2 mg/kg) are (longer1most often used.

Analgesia - NSAIDS
Act to modulate nociception in the periphery and spinal cord p p p y p Central nervous system is not as complex, therefore central actions of analgesics may be unpredictable unpredictable. Several recent studies have tested NSAIDS on reptiles: p
Trnkova S. et.al. Effect of non-steroidal anti-inflammatory drugs on the blood profile in the green nonantiiguana (Iguana iguana). Veterinarni Medicina, 52, 2007 (11): 507511 (Iguana iguana). Medicina, 507 Hernandez-Divers, S. J. Meloxicam and reptiles - a practical approach to analgesia. Small animal and exotics. Proceedings of the North American Veterinary Conference, Volume 20, Orlando, Florida, USA, 7-11 January, 2006 2006 pp. 1636-1637 y, pp

Assume side-effects as per other species. side-

Analgesia - Opioids
Does not tend to induce statistically significant changes y g g in physiological parameters. DoseDose-dependant response observed with morphine and meperidine i crocodiles with ceiling effects. idi in dil ith ili ff t
Latency of action = 30 min, Duration = 2-2.5 hours. 2-

Analgesia - Opioids
Buprenorphine: P i l agonist with some antagonist properties Partial i ih i i Unpublished studies indicate that this is a much better analgesic in turtles compared to butorphanol.
Kummrow: Pharicokinetical basis for drug recommendations of Burenorphine in red-eared sliders, 2006 AAZV conference red-

Butorphanol: Strong agonist and weak antagonist

Slavky: Morphine but not butorphanol causes analgesia and not respiratory depression in red-eared sliders , 2006 AAZV conference redFleming: Use of thermal threshhold test response to evaluate the antinociceptive effects of butorphenol in juvenile green iguanas , 2006 AAZV conference

Cases
Myiasis in an Eastern Box Turtle

Ketamine 10 mg/kg Medetomidine 0.2 mg/kg Buprenorphine 0 02 mg/kg 0.02 Isoflurane

Cases
Black rat snake

Ketamine 12 mg/kg Medetomidine 0 3 mg/kg M d idi 0.3 /k Buprenorphine 0.04 mg/kg Isoflurane