Anesthesia For The Pet Practitioner 2009 2 PDF

Anesthesia
for the Pet Practitioner

Second Edition
Dr. Patriquin and Korey
ANESTHESIa FOR THE PET PRaCTITIONER

SECOND EDITION
2008 Banfield, The Pet Hospital ISBN 978-0-9743262-3-8 Reproduction of the whole or any part of the contents without written permission of Banfield, The Pet Hospital, is prohibited.
Dr. Yarbrough and Samson
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DEDICATION
Contributing Authors
Karen Faunt, DVM, MS, DACVIM Vice President, Chief Medical Officer Nancy Townsend Zimmerman, DVM, DABVP Director of Medical Support Kathy S. Engler, DVM, DABVP Medical Director Oregon & SW Washington Gary Goldstein, DVM, FAVD, DACVD Ashley Harris, DVM, DABVP Medical Advisor Robyn Hauser, DVM, DABVP Medical Advisor Ed Loebach, DVM Heather Stratton, Team Lead Quality Assurance/Medical Support Luis Tello, DVM Medical Advisor C. Lee Tyner, DVM Animal Health Center Director Professor of Clinical Sciences College of Veterinary Medicine, Mississippi State University
Welcome to the Second Edition of Anesthesia for the Pet Practitioner. In order to deliver the best care for our patients, we continue to review our anesthesia protocols and procedures so that we can offer the latest medical information and technology to youour doctors. This edition includes a wealth of new information, from updated protocols and drug dosages to new sections on dental nerve blocks, perioperative antibiotics practice guidelines, and practice standards for multiple procedure anesthesiaall in an easy-tonavigate format. A number of individuals were instrumental throughout the process of creating this book. Id like to extend my appreciation to Dr. Lee Tyner, whose expertise was vital in creating the first edition. Thank you to our medical advisors, who contributed their knowledge and editing skills: Dr. Nancy Townsend Zimmerman, Dr. Robyn Hauser, Dr. Ashley Harris, Dr. Ed Loebach and Dr. Luis Tello. Their input was invaluable. Thanks also to Dr. Kathy Engler for devoting a great deal of time and effort updating, adding to, and revising the protocols and notes in this and the previous edition. Id also like to thank Heather Stratton, team lead of Quality Assurance/Medical Support, for her participation, and Amy Walker, PMP, project manager, for her efforts in coordinating workflow with everyone involved. In addition, Id like to thank the Publishing TeamKathy Baumgardner, senior director, Practice Communications, Sharon DeBusk, medical editor, Nina Silberstein, medical writer/copy editor, and Jovonda Schafrik, graphic designerfor their help in editing this book and making it coherent and user-friendly. Finally, I want to acknowledge our medical directors and doctors who serve on our Peer Review Committee. As mentors, they guide us through our peer review process, enabling us to evaluate and learn from our experiences. It is my hope that the information within the pages of this handbook will help us all in giving Pets the same care we want for ourselves and to treat Pets like family.
Editorial Team
Kathy Baumgardner Senior Director, Practice Communications
Karen K. Faunt, DVM, MS Diplomate ACVIM Small Animal Chief Medical Officer Banfield, The Pet Hospital
Sharon DeBusk Medical Editor Nina Silberstein Medical Writer/Copy Editor Jovonda Schafrik Graphic Designer Amy Walker, PMP Project Manager
Banfield, The Pet Hospital 8000 N.E. Tillamook St. Portland, OR 97213 800.838.6738 www.banfield.net
Dr. Faunt and Bogart
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Table of Contents
Section 1: Introduction to Anesthesia....................1 Autonomic Nervous System............................... 3 Anesthesia Commitment Document................... 5 Fractious Pets...................................................... 6 Perfusion............................................................. 7 General Requirements and Definitions............... 8 Perioperative Antibiotic Best Practice Guidelines......................................................... 11 Practice Standards for Multiple Procedure Anesthesia........................................ 13 Premedications.................................................. 15 Induction Agents............................................... 17 Intubation.......................................................... 19 Maintenance Agent........................................... 20 Oxygen Flow Rates........................................... 20 Assisted Ventilation.......................................... 20 Fluid Administration......................................... 21 Monitoring........................................................ 21 Blood Pressure.................................................. 21 End Tidal CO2................................................... 22 Hypothermia..................................................... 22 Anesthesia Monitoring and Emergency Protocol Algorithm........................ 23 Pain Management. ............................................. 24 NSAIDs Washout Chart.................................... 27 Anesthesia Task Pain Chart. .............................. 28
Dr. Hughes and Dublin
Dental Nerve Blocks....................................29-34 Techniques for Epidural Analgesia................... 35 Anesthesia Equipment.................................37-48 IV Catheter Sizes............................................ 37 Rebreathing Bag Sizes...................................... 37 Endotracheal Tube Selection. .......................37-38 Breathing Circuit Guidelines............................ 38 Non-rebreathing Circuit.................................... 38 Care of Circuits and Cleaning........................... 38 Oxygen Cylinders............................................. 39 Soda Lime Canisters......................................... 39 Safety Pressure Relief Valve............................. 40 Evacuation System............................................ 40 Pop-off Valve Functional Settings.................... 41 Regulator........................................................... 42 Manometer........................................................ 42 Vaporizer and Anesthesia Machine Service...... 43 Anesthesia System Flow Chart......................... 44 Troubleshooting Guide................................46-48 Section 2: Banfield Protocols................................49 Pre-Anesthetic Evaluation................................ 49 Anesthesia Decision Protocol........................... 50 Banfield Anesthesia Protocol............................ 51 Anesthesia Cycle. .............................................. 52 Canine/Feline Anesthesia Physical Examination. ....................................... 54
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Table of Contents
Laboratory Data................................................ 56 Pre-Anesthetic Blood Work Evaluation............ 57 Healthy Pet Protocol: Soft Tissue Surgery. ....... 58 Fractious Pet Protocol....................................... 59 Feline Declaw Protocol..................................... 62 Lipemia Protocol. .............................................. 64 Abdominal Protocol.......................................... 66 Cardiac Protocol. ............................................... 68 Hepatic Protocol. ............................................... 70 Stable Diabetic Protocol................................... 72 Non-Stable Diabetic Protocol........................... 73 Pulmonary Protocol.......................................... 74 Obesity Protocol. ............................................... 76 Renal Protocol. .................................................. 78 Post-Renal Protocol.......................................... 79 Orthopedic Protocol.......................................... 80 Ear Surgery Protocol......................................... 81 CNS & Eye-Globe Protocol.............................. 82 Emergency Surgery Protocol............................ 83 Pediatric Pet Protocol. ....................................... 84 Anesthesia Monitoring and Emergency Protocol................................... 86 CPR Protocol.................................................... 87 Cardiopulmonary Arrest. ................................... 88 Patient Anesthesia Monitoring Form................ 90 Section 3: Fluid Therapy in Pets..........................91 Crystalloids....................................................... 91 Colloids............................................................. 92 Shock................................................................ 93 Intraosseous Route for Fluid Therapy. .............. 93 Section 4: Anesthetic Considerations for Small Exotic Pets. ............................................95 Introduction....................................................... 95 Avian Anesthesia Protocol.............................. 104 Reptile Anesthesia Protocol............................ 106 Ferret Anesthesia Protocol.............................. 108 Rabbit Anesthesia Protocol............................. 110 Guinea Pig and Chinchilla Anesthesia Protocol........................................ 112 Rat, Mouse, Gerbil and Hamster Anesthesia Protocol........................................ 114 Hedgehog Anesthesia Protocol....................... 116 Exotic Patient Anesthesia Monitoring Form. ... 118 Section 5: Appendix.............................................121 Acepromazine................................................. 122 Butorphanol. .................................................... 123 Diazepam........................................................ 124 Diphenhydramine. ........................................... 125 Morphine......................................................... 126
Propofol.......................................................... 127 Telazol............................................................. 130 Ketoprofen...................................................... 133 Atropine.......................................................... 134 Glycopyrrolate................................................ 135 Ephedrine........................................................ 136 Lidocaine. ........................................................ 137 Dexamethasone............................................... 139 Atropine (for CPR)......................................... 140 Epinephrine..................................................... 141 Sodium Bicarbonate........................................ 143
Table of Contents
Henri
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Linda and Baxter
Introduction to Anesthesia
INTRODUCTION
Anesthesia for the Pet Practitioner began more than a decade ago as a loose collection of notes on our protocols. It evolved into a manual designed as a job aid for our doctors and then took on a life of its own when we started sharing it with the profession. Our goal is to present our most current thoughts, policies and standards on anesthesia in a user-friendly format. As such, you will notice that most of this handbook is in outline form and is intended to be an easy-to-use guide and not a definitive source of all available information on anesthesia. This second edition includes several new topics such as fluid therapy and pain management, as we learned that more information on these subjects was needed. We hope this handbook will be helpful. It will constantly evolve as we strive to continually improve our anesthetic outcomes. When considering which anesthesia methodologies you are going to adopt for your practice, the question should be asked, How do you determine quality for anesthesia? If practitioners agree that improved case outcomes are a good measure of quality for anesthesia, then we have a starting point to develop standards of practice for anesthesia in general practice. Better quality is positive for the profession as a whole and for the Pets we treat. Banfields anesthesia standards and protocols are a result of this thinking. The question we posed to ourselves in 1998 was, Can anesthesia methods be developed that would decrease the mortality rate as well as other adverse case outcomes associated with anesthesianot only for one hospital, but for hundreds of hospitals? This challenge forced the question, Is anesthesia an art or a science? If it is art, then the mortality rate is based on intuition and experience. If it is science, then the outcome of anesthesia should be repeatable with standardized methodologies. Based on our experience, we believe that anesthesia is more science than art. We evaluate all anesthetic deaths and significant complications from the nearly 300,000 general anesthetic procedures completed in our hospitals per year. This ongoing outcome analysis is part of our peer review processa concept taken from human medicine that is similar to morbidity and mortality rounds. Peer review, combined with standardized software, drug formulary and equipment, removes many of the variables seen by the profession and has improved our anesthesia case outcomes.
Section 1:
Measuring quality
Quality anesthesia can be measured in a number of ways. The primary method chosen by Banfield is mortality rate. All anesthesia-related deaths are taken through our peer review process, and many of these cases also have necropsy results. This provides data on a large enough sample size to identify patterns that affect mortality. The same factors that affect mortality likely also affect morbidity; thus, reducing mortality will hopefully reduce morbidity. Research studies on anesthesia methodologies and case outcomes in the profession are rare. A study involving 250 small animal practices in Canada, in which all used isoflurane as the standard, revealed a mortality rate of approximately one death per 1,000 anesthesias.1
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Table 1: Banfield Anesthesia Mortality Data
3. Lack of understanding regarding proper drug usage and effects is common. 4. Development of unique protocols (i.e., bypassing standards) increases mortality. Anesthesia is often considered to be synonymous with the anesthetic medications used. While the choice of anesthetic agents is important to case outcome, it is only a small portion of complete and successful anesthesia. In our view, it is also important to look at how the pharmacology of the anesthetic agents affects patient perfusion while maintaining a state of consciousness that allows a procedure to be performed. To accomplish perfusionmaintenance, other factors besides pharmacology need to be considered. A total system for anesthesia is necessary and consequently results in the development of standards and protocols to address each component of anesthesia and not just drug choice. Our definition of a complete anesthesia system includes equipment, evaluation of the patients health status (including blood work), drugs employed and monitoring. Additionally, drug selection must be based on a working knowledge of drug interactions and their effects on perfusion. For example, if a patient is sedated with acepromazine, will that affect the safety margin of an alpha-2 agonist? Or, if ketamine is used for an aggressive cat, should atropine be given to prevent bradycardia? Not all drugs are compatible. Their physiological effects need to be understood well enough to be certain of compatibility. Well-thought-out protocols and standards help ensure that the matrix of premedications, induction agents, maintenance agents and emergency drugs will all work in synergy. There certainly is more than one way to practice anesthesia and achieve successful outcomes. Doctors can get similar results, provided that all components of the total anesthesia system equipment, monitoring, medications, etc.are consistently utilized (standards and protocols employed), and drug selection and dosages are compatible. In conclusion, as a profession, we should never be satisfied with even very low morbidity and mortality rates with anesthesia. We should strive to make continual improvement at all times.
References 1. Dyson et al. Morbidity and mortality associated with anesthetic management in small animal veterinary practice in Ontario. J Am Vet Med Assoc. 1998;34(4):325. 2. Moore GE, Burkman KD, Carter MN, et al. Causes of death or reasons for euthanasia in military working dogs: 927 cases (19931996). J Am Vet Med Assoc. 2001;219(2):209-214.
It is reasonable to assume that in the United States, the average small animal veterinary practice may have similar mortality rates. A study by the U.S. Army Veterinary Corps reviewed all deaths and euthanasias of 927 military working dogs from 1993 to 1996, including anesthetic deaths. Anesthetic arrest was noted in 10 of the 927 dogsa rate of approximately 1 per 100 patients.2
When we began developing our anesthesia protocols in 1998, our anesthesia mortality rate was approximately 12 per 10,000 procedures. Our goal was to achieve a mortality rate of 1 per 10,000 procedures. We were able to achieve this within two years by developing and instituting internal standards (equipment, formulary and protocols). These findings were originally reported on case reviews for 69,000 procedures over four years (Table 1) and have continued through the present time. We also continue to find that when doctors create unique, personal protocols the mortality rate increases four-fold. At a mortality rate of 1 per 10,000 procedures, a doctor averaging four general anesthesia procedures per day and working 220 days per year, would have, on average, one fatal complication every 11.4 years. While this is an admirable goal and achievement, our goal is to continue to improve the safety of anesthesia in our practice. While improved mortality rates are desirable, we also want the Pets condition to be equal to or better than its condition prior to anesthesia. All adverse events, even non-fatal, are critically important when determining quality anesthesia. For instance, poor perfusion doesnt always result in patient death, but it could result in behavior changes or cortical blindness due to a hypoxic event that damages brain tissue during anesthesia. While these outcomes are not fatal, they are adverse anesthesia events, nonetheless. While our peer review process touches on this, we are working to enhance our understanding and assessment of anesthetic complications.
Standards and protocols

Our peer review process has revealed the following: 1. Anesthesia reactions are truly very rare. 2. Standardizing anesthesia protocols decreases mortality rates.
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Figure 1: Autonomic Nervous System: Drugs & Their Cardiovascular Effects
KEY
ACH=Acetylcholine NE= Norepinephrine HR = Heart rate (-) = Inhibition (antagonist) (+) = Stimulation (agonist) * Ephedrine causes a release of norepinephrine
(+) Bethanechol
Nicotinic
Parasympathetic Cholinergic
(-) Atropine (-) Glycopyrrolate
Nicotinic
PerIPheral Nervous System
CENTRAL NERVOUS SYSTEM
ACH
eti c
ath
(-) Alpha-1 antagonists (-) Phenoxybenzamine (-) Acepromazine (+) Norepinephrine (+) Epinephrine (+) Isoproterenol (+) Dobutamine & Dopamine (-) Beta Antagonists (-) Propranolol (-) Atenolol (+) Epinephrine (+) Isoproterenol (+) Albuterol & Terbutaline (-) Propranolol
Sy mp
ACH
Sy
NE
a mp
the
tic
NE
(+) Norepinephrine (+) Epinephrine* (+) Dopamine (+) Neo-Synephrine (+) Ephedrine (phenylephrine)
muscarinic
(+) Medetomidine (+) Xylazine (-) Yohimbine
Eye contract iris (miosis-miotic) Heart A-V block, decrease HR and conduction velocity Lung stimulate secretion
ACH
ACH
Arterioles (coronary, skeletal, cerebral, skin, and viscera) constrict Veins constrict
Heart increase HR, contractility, automaticity, conduction velocity Adipocytes lipolysis
ACH
NE
Sympathetic
Arterioles dilate peripheral vessels Veins dilate peripheral vessels Lungs relax bronchial muscles
THE AUTONOMIC NERVOUS SYSTEM

Reviewing the autonomic nervous system provides an understanding of how drugs used during anesthesia affect perfusion. This includes their effect on cardiac output. Note the following drugs in Figure 1 as they are key drugs in the discussion of the autonomic nervous system and our anesthetic protocols: Atropine. Glycopyrrolate. Acepromazine. Neo-Synephrine. Ephedrine. Dobutamine. Epinephrine.
The beta-1 pathway must be stimulated if the heart rate is to be increased above the basal rate, as seen with norepinephrine or epinephrine release/administration or dobutamine administration. Anticholinergic administration blocks the ability of the heart to slow in response to appropriate vagal stimulation. In our experience, this may result in unwanted tachycardia. In our opinion, when using our protocols, patients with a normal heart rate before anesthesia rarely benefit from preemptive anticholinergic administration. Tachycardia after anticholinergic administration is difficult to manage. Supporting subsequent increased myocardial oxygen demand with supplemental oxygen and administering intravenous fluids to support circulating volume is helpful. Fluid loading to stimulate stretch receptors may help decrease the heart rate, thus increasing cardiac output and improving cardiac perfusion. If tachycardia is present prior to anticholinergic administration, give supplemental oxygen and IV fluids and postpone induction of anesthesia until the heart rate normalizes or the primary cause is identified and treated. Due to the reasons noted above, Banfield protocols call for anticholinergic administration only when the preoperative physical examination reveals bradycardia or if bradycardia develops during a procedure.
Parasympathetic cholinergic pathway

Stimulation slows the heart rate. Administration of an anticholinergicglycopyrrolate or atropinedoes not increase the heart rate above the basal rate but decreases vagal tone by blocking the effects of acetylcholine on the sinoatrial node. Heart rate may be elevated after administration of these drugs due to the presence of epinephrine in the system affecting the beta-1 pathways.
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Alpha-1 sympathetic pathway

Stimulation results in arteriole and venuole constriction. Blockade results in arteriole dilation. For example, administering Neo-Synephrine, an alpha-agonist, Alpha-1 sympathetic pathway induces vasoconstriction. Administration of acepromazine, an alpha-antagonist, blocks this pathway in a dose-dependent manner. Blockade of the pathway limits vasoconstriction and may result in lower blood pressure. Therefore, alpha-1 stimulation causes arteriole constriction. Alpha-1 blockade results in arteriole dilation.
Beta-2 pathway
Stimulation results in bronchodilation and dilation of the vascular bed within the skeletal muscle. This physiological change is most commonly noted in the fight or flight response. Albuterol is an example of a beta-2 specific agonist.
Central alpha-2 agonists

Excellent analgesic properties. Effects on the higher centers in the central nervous system (CNS). Causes peripheral vasoconstriction and rebound bradycardia and decreased cardiac outputperhaps by as much as 40 percent. Usefulness is limited to healthy patients able to tolerate or compensate for a decrease in cardiac output. Use of alpha-2 agonists as intermediate acting anesthetics without performing a complete health evaluation can be problematic. If undiagnosed cardiovascular disease is present, the risk factor is high. Therefore, central acting alpha-2 agonists are not used in our protocols. Xylazine and medetomidine are examples of alpha-2 agonists.
Beta-1 pathway
Stimulation increases heart rate and contractility, thus increasing cardiac output if all else remains normal. Dobutamine is an example of a beta-1-specific agonist.
Beta-1 pathway
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ANESTHESIA COMMITMENT DOCUMENT PERMISSION TO STOP!

As medical professionals, we are often driven by the dictum, "First, do no harm." Holding ourselves accountable to that guiding principle may require that we elect to not continue with a procedure due to the risk of injury or death to the Pet. At Banfield, we expect doctors to do the best thing for the Pet at all times. It takes knowledge, experience and courage to ensure that you do not allow outside forces such as scheduling, production value, client perception, or any other circumstance to influence you to proceed with an anesthetic procedure that is contraindicated based on any abnormal pre-anesthetic test or physical exam finding. After years of performing peer reviews on cases with unexpected or poor outcomes, one of the most common threads among them, in hindsight, is poor decision-making. If even mild abnormalities exist in the pre-anesthetic blood work or physical examination findings, heed the warning. If you do not look at the results and respect the results, why do the test? If a cat or dog cannot be handled in a reasonable manner, is it worth risking the Pets life? If you have already lost control of the Pet, STOP! If you have a gut feeling that you should not go forward, dont! Its not just how much you know, but how you apply it that counts. Each time you see the following sign in this handbook, remember to stop and make sure what you are about to do is the right thing for this Pet today.
Avoidable situations: 1. Aggressive Pet: It is not worth risking injury to your team or the Pet if it requires excessive restraint or you have a failed attempt at sedation. Stop. Start the process another day, if possible, with a different, better plan. 2. Blocked cat: Do not anesthetize a cat with urethral obstruction without first administering pain medication, performing cystocentesis, and stabilizing the patient with IV fluids and electrolyte abnormality correction. The blockage is not the emergency; renal failure and electrolyte imbalances are the problem. The heart stopping due to hyperkalemia may be life-ending long before the post-renal effects of physical obstruction on the patient are. 3. Immobilization of brachycephalics (Persians, Bulldogs, Pugs, etc.): Place an endotracheal tube in these patients and dont take it out until they are walking away from it. These Pets need constant monitoring to avoid asphyxiation. It is also important to remember that patients in your hospital who are receiving care from an outside surgeon or consultant are still your responsibility as it pertains to anesthesia protocol, monitoring guidelines and documentation. In signing this page, you, the doctor, are committing to the Pets in your care that you will make the best choices with their life even if it means inconveniencing the client at times. The client may not appreciate the gravity of the situation, and it may affect your relationship in the short run, but first, your duty is to the Pet.
Think. Make a good decision.
Signature
Date
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FRACTIOUS PETS Think. Make a good decision.

Fractious Pets release a significant amount of catecholamines that lead to physiological effects such as tachycardia, hypertension, tachypnea, anxiety, muscle splinting, twitching, shivering, hyperthermia, salivation and mucous membrane color change. All these effects increase the risk of anesthesia in fractious Pets. Close monitoring of the cardiovascular, respiratory and CNS systems is required to anticipate complications and prevent anesthetic accidents. A fractious Pet is predisposed to anesthetic risk and is defined as: Requiring more than one PetNurse to restrain.
Acepromazine in fractious Pets and epinephrine reversal: Epinephrine stimulates both alpha and beta 1 & 2 receptors. Epinephrine (natural catecholamine) is often released endogenously during stressful events, as with a fractious Pet; or it can be administered in an emergency as part of CPR. When an alpha-1 antagonist, such as acepromazine, is given as a premedication, it blocks arteriole constriction usually produced by epinephrine through its effect on alpha-1 receptorsin a dose-dependent manner. However, epinephrine is still able to stimulate the beta 1 & 2 receptors. Beta-1 stimulation results in increased heart rate and contractility as well as limiting ventricular filling time. Vasodilation and pooling of circulatory volume in the vascular bed of skeletal muscle occurs because of beta-2 stimulation. This inhibits venous return and decreases cardiac output. Acute relative hypovolemic shock may develop. It is imperative to avoid acepromazine in the fractious Pet. Therefore, the Fractious Pet Protocol (See page 59) does not include acepromazine. Treatment of epinephrine reversal requires the administration of a shock dose of fluids: Dog: 20 to 40 ml/lb/hr. Cat: 10 to 20 ml/lb/hr.
Requiring more than one attempt at venipuncture because of aggression or demonstrating any signs of aggression. Any and all overt displays of aggressive behavior. With feline patients, cardiomyopathy is often subclinical and not evident until the cat is challenged or the disease is very advanced. Hypertrophic myocardial changes render patients more susceptible to myocardial hypoxia and ischemia. During stressful episodes such as anesthesia and surgery, there is a release of catecholamines that leads to acceleration of the heart rate, reducing cardiac filling time and myocardial perfusion, thereby, aggravating diastolic dysfunction that may precipitate left heart failure and pulmonary edema.
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PERFUSION
Defining good perfusion: A state of adequate blood flow and volume to push red blood cells to the lungs, pick up oxygen and deliver it to the tissues. Or more simply, nicely filled blood vessels, which means having adequate circulating blood volume, blood pressure, oncotic pressure and cardiac output to maintain normal perfusion (Figure 1.1). Anesthesia maintenance: Because anesthetic drugs affect perfusion, and most drug effects are dose-dependent, one must understand the mechanisms of how drugs alter perfusion during anesthesia. Understanding this is the first step toward maintaining perfusion during anesthesia. Review of cardiac output (CO): CO = heart rate x stroke volume (HR x SV). Stroke volume is dependent on venous return (preload), total peripheral resistance (afterload) and cardiac contractility. The heart acts as a pump that pushes a determined volume of liquid (blood) to the body. The amount depends on how much liquid there is inside the pump before it is pushed out (preload); the mechanical power of the pump (contractility); and the resistance (afterload) the pump has to work against to push the liquid as far as possible. Cardiac output is fundamental to perfusion. Patients with excessively high heart rates may have stroke volumes so small that cardiac output is severely compromised. A cat with a heart rate of 250 beats per minute has marginal cardiac output due to decreased ventricular filling. If the vagal system is blocked, the heart cant slow itself and death may occur from a lack of cardiac output. It is important to note that preload (venous return) and afterload (peripheral resistance) affect cardiac output. In hypertensive patients, cardiac output is decreased because the heart is pumping against higher pressures within the smaller vessel size. Circulating blood volume is critical to maintaining blood flow. Banfield protocols include IV fluids to help maintain cardiovascular volume and tissue perfusion that could be compromised during anesthesia.
Blood vessels allow fluid to pass into the interstitial spaces, thus, oncotic pressure affects perfusion. If albumin and total protein levels are below normal, pulmonary edema may result from fluid movement into the interstitium. Patients who develop pulmonary edema during anesthesia may not show signs until several hours later. This is one of many reasons that patients must be monitored for at least two hours post-anesthesia.
Figure 1.1: Good Perfusion & Receptor Sites
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Introduction to Anesthesia PAGE 7
GENERAL REQUIREMENTS FOR ANESTHESIA AND DEFINITIONS General information

At all times, every medical team must comply with individual state practice acts. It is each doctors responsibility to know and understand the requirements of his/her specific state, as well as Banfields policies and procedures. Specifically, the doctor should ensure compliance with state regulations regarding the handling and administration of controlled substances, intubation of Pets, anesthetic monitoring and drug administration documentation, and determine which hospital associates can legally perform dental prophylaxis or other medical procedures. The following are Banfield's standards which must be met in addition to any state regulations.
mean less pain management. And, if you lower the dose of the tranquilizer in the premeds, you will need to use a higher dose of induction agent and maintenance agent. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has been fully recovered for at least two hours.
Definitions and requirements

The requirements listed in the following categories are the minimum practice standards. If additional measures such as an IV catheter for an immobilized patient are prudent, please take them. When using anesthesia agents, charge the appropriate fee.
Tranquilization/sedation
Definition: The patient can walk. Use tranquilization/sedation for blood collection and otoscopic exam, to assist in restraint for non-painful procedures and to help decrease anxiety. Requirements: Complete and deliberate physical examination (PE). Monitoring of temperature, pulse, respiration (TPR) and pulse quality every 15 to 60 minutes depending on patient, with visual observation at all times. Depth of tranquilization is such that endotracheal tube placement is NOT possible. Heart monitor (ECG) or pulse oximeter to be used at the doctors discretion. IV catheter to be used at the doctors discretion and is recommended for Pets older than 5 years of age. For tranquilizing a patient in the hospital: Butorphanol: 0.1 to 0.2 mg/lb SC or IM (5 mg maximum dose) plus one of the following three agents: Acepromazine: 0.025 mg/lb SC or IM (1.5 mg maximum dose). Do NOT use on a fractious Pet. Can use alone or in combination with butorphanol. Diazepam: 0.1 mg/lb IM. Can use alone or in combination with butorphanol. Diphenhydramine: 1 mg/lb SC or IM (50 mg maximum dose). Can use alone or in combination with butorphanol. For air and ground travel: Inform owners that oral sedatives have variable effects on Pets and are more effective when administered before the Pet becomes anxious or excited. Owners will need to closely monitor their Pets reaction to the sedative and consult with the doctor for dosage adjustments. It is best to start with minimal doses.
All patients must be examined by the doctor prior to being sedated, immobilized or premedicated (fractious Pets are the exception) and again prior to induction of anesthesia. The results of these examinations should be documented in the medical notes. When initially following new anesthesia protocols, the entire medical team should always monitor and closely observe the patient, from premed administration through recovery from anesthesia. This close observation by the doctor and PetNurse provides a greater understanding of how each drug affects the patient. Particularly close observation should occur for the first five anesthetic procedures in which a new protocol is employed. All anesthesia protocol information is based on the expectation that anesthetic delivery and monitoring equipment is in proper working order. It is the responsibility of the attending doctor to ensure that the equipment is working correctly. General anesthesia protocols require a PetNurse to monitor the patient and document/record monitoring parameters from induction through recovery. This includes dental procedures in which one PetNurse should monitor anesthesia while another PetNurse or veterinarian performs the procedure, as allowed by your state practice act. Drugs affect individual patients differently. The attending doctor is responsible for knowing the patient and understanding Banfields anesthetic system to appropriately choose protocols and determine specific drug dosages. Changes in drug dosages should be based first on the health status and second on the temperament of the patient. The doctor is responsible for defining the safe dosage for the individual patient. Do not exceed maximum dosages. When selecting a dosage, remember that minimal dose usually equals minimal risk, however it is important to keep in mind that the lower dose on pain medications will also
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Recommend a test dose in advance of travel to evaluate Pets response. Pets should be acclimated to their carrier to decrease the stress that leads to barking, anxiety and hyperexcitability. Placing a favorite blanket in the carrier and feeding the Pet or offering treats while in the carrier also helps. Clients should start acclimating their Pet at least two weeks before their departure. For Pets traveling by air: Banfield will NOT give or prescribe acepromazine or other phenothiazine-type tranquilizers to Pets traveling by air. Phenothiazine derivatives, such as acepromazine, block alpha-1 adrenergic receptors in the circulatory system, resulting in vasodilation. This may create susceptibility to hypothermia and an inability to respond to changes in atmospheric pressure and temperature should a Pet be in the cargo hold when something goes wrong. It is possible for Pets to die during air transport as a result of phenothiazine tranquilization. Prescribe diphenhydramine. It will usually cause drowsiness without circulatory side effects. Calculate the dose for each Pet: 1 mg/lb by mouth up to a maximum dose of 50 mg. Medication should be given approximately one hour prior to travel. The dose can be repeated every six to eight hours as needed. Recommend nonstop flights to minimize stress. Pets often get cold or hot while the plane is sitting on the ground. For Pets traveling by ground: Oral agents that can be prescribed: Diphenhydramine: 1 mg/lb PO q six to eight hours (maximum dose 50 mg). Diazepam: 0.1 to 0.2 mg/lb PO q six to eight hours (script out oral tablets). Acepromazine: 0.25 to 1 mg/lb PO q six to eight hours. See phenothiazine precautionary notes in previous section.
Mild ear cleaning. Pedicure in aggressive patients. To enable handling of fractious Pets requiring general anesthesia (See Fractious Pet Protocol, page 59). Requirements: Complete and deliberate physical examination (PE) except for fractious Pets (for Fractious Pets, complete the PE once immobilized). Depth of anesthesia is such that endotracheal tube placement is not possible. (If an endotracheal tube can be placed, the patient is considered to be experiencing general anesthesia, and all required supportive and monitoring measures noted in the General Anesthesia section are necessary.) Even if an endotracheal tube cannot be placed, the proper endotracheal tube should be readily available in case of an emergent need. Continual monitoring and observation of all vital functions by PetNurse and/or doctor. Record pulse, pulse quality, respiration and depth every five to 10 minutes until recovery; temperature every 15 to 30 minutes. Pulse oximetry. Since a swallow reflex is still present, the sensor will likely have to be used on alternative areas of the bodyi.e., ventral tail base, rectum, toe web, vulva, prepuce, ear, lip. An IV catheter is required for propofol and at the doctors discretion for Telazol (Fort Dodge Animal Health). Direct venous access for administration of fluids or drugs is highly recommended and decreases patient risk, especially for those of uncertain health status. If a Pet is immobilized and the doctor finds the procedure is more extensive than anticipated and requires general anesthesia, then pre-anesthetic blood work, IV catheter and appropriate pre-anesthetic medications MUST be completed prior to induction of general anesthesia. The following agents are used to immobilize patients: Telazol: 0.5 to 2 mg/lb IM only. Use low doses with debilitated patients. Maximum single dose is 100 mg. Telazol is a combination of drugs [a dissociative agent (tiletamine) plus a tranquilizer (zolazepam)] that may cause side effects: respiratory depression, hypothermia, cardiac arrhythmias, seizures, etc. These side effects are dose-related and 100 mg is the recommended maximum dosage to avoid the undesired effects. Propofol: 1 to 4 mg/lb IV.
Immobilization
Definition: The patient cannot walk, is experiencing a nonsurgical plane of anesthesia, can be aroused with minimal effort, and maintains laryngeal and withdrawal reflexes. Use immobilization for procedures that can be completed in less than 10 minutes, are not painful and do not require general anesthesia, such as: Clipping matted hair. Radiographs that do not require special positioning.
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DO NOT immobilize brachycephalic dog or cat breeds. Because of the potential for apnea and/or airway obstruction resulting in hypoxemia and/or hypercarbia in apparently healthy brachycephalic breeds (Figures 1.2 and 1.3) during immobilization, Banfield recommends general anesthesia in all patients with potential for upper airway or pulmonary compromise. These include: All brachycephalic breeds (dogs and cats). Those with excessive pharyngeal folds, such as Shar Peis. Any Pet with concern for abnormalities of the pharynx, larynx, trachea and esophagus, i.e., trauma, mass lesions, etc. This allows for immediate maintenance of a patent airway with an endotracheal tube and ventilatory support with 100 percent oxygen. All general anesthesia prerequisites and monitoring procedures are necessary in these cases. The goal is preventing unnecessary deaths during immobilization in a high-risk group of patients.
Figure 1.2: Brachycephalic Breed (Bulldog)
Figure 1.3: Brachycephalic Breed (Persian)
General anesthesia
Definition: The patient cannot walk, has no gag reflex, is unconscious and has greatly diminished pain response. Use for radiographs requiring special positioning (hips, etc.), surgical procedures, invasive diagnostic procedures and painful procedures. Requirements: Complete and deliberate physical examination. Food and water withheld for a minimum of two hours (attending doctor to determine appropriate fasting time depending on Pet and procedure; there are separate guidelines for exotic patients). Longer periods (i.e., 12 hours) without food can result in hypoglycemia, especially in pediatric patients. Complete blood count (CBC) and internal organ function screen within 48 hours prior to induction. IV catheter. Endotracheal tube placement. ECG and pulse oximeter. Continual monitoring and observationrecord in medical record every five to 10 minutes until recovery. (See Anesthesia Monitoring and Emergency Protocol, page 86). IV fluid support for procedures longer than 10 minutes. Use the following for general anesthesia: Premedications according to anesthesia algorithms. Induction according to anesthesia algorithms. Maintain with oxygen and sevoflurane. Supportive care and post-op pain management according to anesthesia algorithms. Monitor according to anesthesia flow chart and monitoring algorithms. Be sure to comply with all state regulations in addition to those listed in the monitoring algorithms. Patient evaluation: Perform pre-anesthetic blood work (CBC and internal organ function screen) within 48 hours prior to anesthetic induction. See Canine/Feline Physical Examination, page 54, and Pre-anesthetic Blood Work Evaluation algorithms, page 57. Address any abnormalities prior to proceeding with anesthesia. Review the patients medical record completely. Confirm that all participating associates are aware of every procedure being performed on the patient.
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Perioperative Antibiotic Best Practice Guidelines

The Protocol Committee has reviewed published papers in human and veterinary medicine on the usage of perioperative antibiotics. Based on the evidence contained in these papers, the following is a summary of those papers and a recommendation for practice policy. Several studies have reported a protective effect of antibiotic prophylaxis.1,2,3 Surgical site infections can be reduced by a factor of six to seven times with prophylactic antibiotic use.1 The intended purpose of prophylactic antibiotic treatment is to reduce the level of intraoperative bacteria below the critical level that would cause infection.1 It is not intended to eliminate postoperative contamination. Surgical time, experience of the surgeon, wound contamination level presurgery, obesity, the number of paraprofessionals in the surgical room, patient debilitation (need for ICU care), and presence of foreign material such as a drain, were all associated with increasing risk of postoperative infection. The risk of infection was shown to double every 70 minutes of surgical time.1 Each additional person in the surgical suite increased the risk by a factor of 1.3.1 We recommend the usage of preoperative prophylactic antibiotics in the practice due to several factors: Surgical experience differs greatly among doctors. Surgical time is directly correlated to experience. Pets receiving propofol as an induction agent are 3.8 times more likely to develop postoperative infections.4 Improper handling of the product without attention to sterile protocol is responsible for this occurrence. Postoperative surgical site infection rates vary from 2 percent to 5 percent in the literature. This is not acceptable if we wish to treat Pets with the highest quality of medicine as possible. There is evidence that the use of perioperative antibiotics reduces the chances for infections.1 There is no evidence that antibiotic resistance occurs, just anecdotal feelings. The selection and timing of prophylactic antibiotics is important. The injection must occur prior to surgery or at the time of incision to be effective. The type of surgery and the type of preoperative contamination are factors in determining which antibiotic is most appropriate. SOFT TISSUE SURGERY: Ampicillin must be administered at least one hour preinduction to reduce the chances of protein-binding interferences with the anesthetic agents. Two hours would be more ideal so Pets can be observed for any potential anaphylactic reactions. Ampicillin is useful for routine sterilization surgeries and other soft
tissue surgeries. However, ampicillin has been shown to be of no benefit in bacteremia associated with dental scaling. It has excellent efficacy against beta-hemolytic Streptococci, Enterococcus faecalis, obligate anaerobes and Pasteurella multocida.5 Ampicillin should be dosed at 10 mg/kg IM and repeated at six to eight hour intervals if necessary. DENTAL PROCEDURES: The use of systemic clindamycin and topical chlorhexidine is associated with the highest levels of reduction in oral bacterial levels.6 Clindamycin ideally should be started two to three days prior to the dental procedure but the oral absorption rate is very rapid and it could be administered in the hospital setting a minimum of two hours prior to anesthesia. Clindamycin does have an intrinsic neuromuscular blocking activity and should be used cautiously with other neuromuscular blocking agents. It is also highly protein bound. The recommended oral dosage is 5.5 to 11 mg/kg PO. Clindamycin should be continued for a minimum of five days post-cleaning if there is evidence that the Pet needs the benefit of extended antibiotic therapy. Chlorhexidine oral rinse solution should be applied to the teeth and gums as soon as proper endotracheal tube placement has occurred to ensure that aspiration of the product does not occur. It has the most benefit if allowed to stay in place for 10 minutes before proceeding with the dental cleaning. ORTHOPEDIC PROCEDURES: Cefazolin is a first generation cephalosporin and has excellent efficacy against Staph intermedius, beta-hemolytic Streptococci and Pasteurella multocida.3 It has good efficacy against E. coli, Klebsiella pneumoniae and most obligate anaerobes.5 Cefazolin is the most appropriate antibiotic for orthopedic procedures or patients with infected skin. Cefazolin can be administered as a slow intravenous (IV) injection at any time during the preoperative or intraoperative period because it is not protein bound. It is most effective when given just prior to the skin incision being made. Cefazolin should be re-dosed if the surgery is over 90 minutes.7 The recommended dosage is 22 mg/kg IV. MISCELLANEOUS PROCEDURES: For applications not listed above, it is recommended that the veterinarian research which bacteria are most likely to be present at the surgical site on the Pet and select the antibiotic most appropriate for the application based on sensitivities. Caution should be used with highly protein bound drugs and observance of any interactions with medications used for anesthesia should be researched. We recommend keeping the number of paraprofessionals present in the surgical suite to the minimum number needed for anesthetic monitoring and proper Pet care. PROPOFOL HANDLING: Propofol should be handled properly. This involves disinfecting the top of the vial with isopropyl alcohol prior to inserting the needle,
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drawing up the propofol as close to injection time as possible, allowing the product to remain in predrawn syringes no longer than six hours and discarding any opened propofol at the end of the day. Adherence to the highest sterile practices when handling propofol can minimize the postoperative infection rate. Perioperative antibiotics are in no way intended to reduce the need for proper patient preparation, sterile surgical practices, proper tissue handling or proper postoperative care. They are not an excuse to practice poor medicine or surgery.
References 1. Eugster S, Schawalder P, Gaschen F, et al. A prospective study of postoperative surgical site infections in dogs and cats. Vet Surg. 2004;33:542-550. 2. Whittem TL, Johnson AK, Smith CW, et al. Effect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery. JAVMA. 1999;215:212-216. 3. Vasseur PB, Levy J, Dowd E, et al. Surgical wound infection rates in dogs and cats. Vet Surg. 1988;17:60-64.
6. Bowersock TL, Wu CC, Inskeep GA, Chester ST. Prevention of bacteremia in dogs undergoing dental scaling by prior administration of oral clindamycin or chlorhexidine oral rinse. J Vet Dent. 2000.17(1):11-16. 7. Budsberg SC, Kirsch JA. Antibiotic prophylaxis in veterinary orthopaedic surgery. Vet Comp Orthop Traumatol. 2001;14:185189.
4. Heldmann E, Brown DC, Shofer F. The association of propofol usage with postoperative wound infection rate in clean wounds. A retrospective study. Vet Surg.1999;28:256-259. 5. Aucoin D. Target: The Antimicrobial Reference Guide to Effective Treatment. 2nd ed. New York: Alfred A. Knopf; 2000.
Dr. Metcalf and Weewolf
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Practice Standards for Multiple Procedure Anesthesia

Purpose The purpose of the Practice Standards for Multiple Procedure Anesthesia is to define and communicate the benefits and risks of performing multiple concurrent procedures requiring anesthesia, elective or non-elective, and how to invoice such procedures appropriately. In the past, performing multiple anesthetic procedures tended to include at least one elective procedure, and the elective procedure anesthesia package was used to reduce the overall cost to the client. Elective anesthesia packages (dental prophylaxis, ovariohysterectomy, neuter, declaw, etc.) are good for Pets, families, and hospital teams because they encourage families to pursue recommended care, ultimately benefiting the Pets health. Packaging these procedures to reduce the overall cost is designed to help bond the family to the practice. In contrast, the use of elective anesthesia packages to artificially reduce the cost of a non-elective procedure causes an increased risk of complications; loss of production for the hospital team and doctor; and reduces the clients perception of the value of medical care provided to the Pet. Background Elective anesthesia packages were designed to overcome barriers to care by making ovariohysterectomy, neuter, declaws, dental prophylaxis procedures, etc., more affordable. Spays and neuters make life better for Pets by reducing overpopulation and reducing stress and injury involved with hormonal influenced fighting and roaming. Affordable access to early preventive dental care reduces dental and gingival disease that can lead to pain, tooth loss, and internal organ disease via translocation of bacteria through the blood stream. With the goal of making non-elective procedures more affordable for families, it is tempting to concurrently perform an elective procedure in order to reduce the cost of the anesthesia. This reduces the price of the anesthesia package and the overall cost to the client. There are several reasons why this is not in the Pets, familys or hospitals best interest: Safety of the PetPerforming elective procedures at the same time as non-elective procedures may increase the risk of complications. Extra anesthesia time poses an unacceptable risk. Increased risk of hypothermia. Increased risk of hypoperfusion. Non-elective procedures should not be performed on sick and, therefore, inherently unstable, patients. Cross contamination of tissue.
Aerosolized bacteria from dental prophylaxis in surgical incisions. Transient bacteremia from dental prophylaxis hematogenously spread to surgical sites. Contamination of spay or neuter site from nonsterile secondary surgery sites. Family perception of serviceThe Pets family is given an inappropriate perception of care provided. Client is not given appropriate appreciation of true cost of care. Client upset if an identical procedure costs more in the future. Dental plus mass removal today and mass removal alone in six months. Client upset when not offered same deal as another client.
Causes inconsistency between cost of similar procedures at different Banfield hospitals. Final invoice becomes complicated if Pet becomes unstable during non-elective portion of surgery and anesthesia is aborted. Hospital team compensationThe hospital team spends more time and resources, but is not fully compensated. Example: fracture repair + spay in combination takes 20 minutes longer than fracture repair alone but the hospital is compensated 30 percent to 40 percent less. The net production available to pay team is lower because gross paid is lower while cost of goods remains the same. Policy In order to maintain good standing with Banfield, all associates must comply with these guidelines. Banfield recognizes that, as with all medical decisions, the doctors must make the decision they feel is medically appropriate for the patient at that time. Elective anesthesiadefinition: Elective anesthesia is anesthesia performed on a healthy or stable Pet in order to perform a surgical procedure which is not vital to the immediate diagnosis or treatment of an underlying disease. Elective anesthesia packages include spay, neuter, canine prophylactic gastropexy, feline declaw, and dental prophylaxis packages. Elective anesthesia candidates: Elective anesthesia procedures are performed on Pets that are healthy or have non-life-threatening or stable conditions such as gingivitis, otitis, heart murmurs with no change in heart function (cardiac output), etc.
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Examples of non-elective procedures: Orthopedic repair, wound repair, abscess flush, mass removal, pyometra, aural hematoma, cystotomy, gastrointestinal surgery, etc. Multiple surgical procedures may be performed at the same time if: There is little or no risk of additional contamination. i.e., oral mass removal and dental prophylaxis. The Pet is stable and there is no reason to be concerned about the total length of anesthesia anticipated. i.e., combination spay, stenotic nares, and soft palate resection. All procedures are necessary to preserve the Pets immediate health. i.e., concurrent repair of traumatic fracture, laceration, and hernia. General rules of deciding how to invoice: Always order primary purpose of anesthesia first.
If primary purpose is non-elective then combining with an elective package is inappropriate. Example: Pyometra: order general anesthesia package, then pyometra with spay surgical fee. Traumatic tooth fracture or tooth root abscess: order general anesthesia package, extractions as needed, then dental prophylaxis if full cleaning needed. Elective anesthesia packages should be used only if all procedures are elective: Example: Dental cleaning with incidental extractions: Order dental prophylaxis package then add extractions (and radiographs) as needed. Feline neuter plus declaw: Order feline castration package then order declaw surgical fee.
Dr. Deckert, Hope and Hunter
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PREMEDICATIONS Purpose:
1. Calm the patient and reduce stress. 2. Decrease the dose of induction and maintenance drugs. 3. Improve induction and recovery quality. 4. Provide initial aspects of multimodal pain management. Note: Do not rely on premedications alone to facilitate venipuncture or catheter placement in fractious Pets. Move directly to Fractious Pet Protocol. In this section, you will find information on drugs used for premedications and pain management, including the time to effect, duration of action, where it is metabolized and how it is excreted. There will also be information about the proteinbinding property of each drug. Protein binding is important as it is the property of the drug that limits distribution and availability in the bloodstream. Only the unbound portion of the drug exhibits the pharmacologic effects and is available for metabolism and excretion. If a drug overdose occurs, the protein binding capacity may be exceeded which leads to excess amounts of free drug in the bloodstream that must be accounted for when attempting to reverse an overdose.
associated with epinephrine release. Provides anti-emetic action. Provides no pain control. Remember: Anything Ace does, fluids can fix. Avoid using in fractious Pets as it can cause epinephrine reversal syndrome. Directions for dilution of acepromazine: Order sterile water for injection and 30 ml empty sterile vials through Banfield Direct. Draw up 27 ml of sterile water with a sterile syringe and add it to the empty sterile vial. Draw up 3 ml of 10 mg/ml acepromazine and add to the same vialthis results in a 1 mg/ml solution. Vial with diluted Ace should be labeled and dated. The solution is light-sensitive, therefore, the vial should be completely wrapped with opaque tape or CoFlex (or a similar product). If protected from light, the solution is stable at room temperature. Do not keep the 10 mg/ml acepromazine in an area where it could be easily accessed by mistake.
Acepromazine (Ace)
A phenothiazine sedative/ tranquilizer. Onset is fairly slow. Peak effects seen 30 to 60 minutes post administration. Has a duration of approximately six to eight hours. 99 percent protein bound. Metabolized in the liver, with conjugated and unconjugated metabolites excreted in the urine. An alpha-1 antagonist: Results in vasodilation of arterioles. Action is dose-dependent, so low doses result in slight vasodilation, and a large dose can result in a relative hypovolemic shock. Helps counteract the hypertension often seen in stressed patients. Should be prediluted to 1 mg/ml to allow for proper and more precise drug measurement. Protects against some arrhythmias including ventricular premature complex (VPC) and ventricular fibrillation
Acepromazine (Ace)
Butorphanol
Partial opiate agonist/ antagonist. Onset begins within a few minutes post IV administration, and within 15 minutes after IM administration. Generally lasts one to two hours. Highly protein bound.
Butorphanol Metabolized in the liver. Metabolites excreted in the urine (86 percent to 89 percent) and feces (11 percent to 14 percent).
Antagonist to mu receptors and can be used as a reversal agent for pure opioids whose analgesic action is mediated through mu receptors, i.e., morphine. Provides pain management through effects on kappa and sigma receptors. Provides good visceral analgesia by acting at the subcortical and spinal levels. Has little to no respiratory depression. Butorphanol administered subcutaneously (SC) in cats is less painful, but absorption may be delayed. Consider the timing and extent of the procedure to be performed when deciding whether to administer SC or intramuscularly (IM).
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IM administration in the epaxial or caudal thigh muscles helps to ensure absorption, especially with a low-volume dosage. Butorphanol is a mixed agonist/antagonist; therefore, a ceiling is reached on its analgesic propertieshigher doses do not proportionally equal more pain management. As higher doses are given, the likelihood of adverse effects developing increases (i.e., dysphoria). To utilize butorphanols analgesic properties but avoid potential adverse effects, the maximum dose a patient should receive, regardless of size, is 5 mg at one time per dose. May need to be redosed every one to four hours to maintain pain control. Class IV controlled substance. Follow Drug Enforcement Administration (DEA) regulations regarding storage, usage and documentation.
higher risk patients, such as the stabilized epileptic requiring a surgical procedure. Class IV controlled substance. Follow DEA regulations regarding storage, usage and documentation. Note: Midazolam, a shorter-acting, water-based benzodiazepine, is substituted for diazepam when it is unavailablethe dose is 0.1 mg/lb SC or IM.
Diphenhydramine
An H1-antihistamine. Rapid onset of action. Duration of approximately six to eight hours. Highly protein bound. Metabolized in the liver and mostly excreted as metabolites in the urine. Competitively antagonizes histamine at H1 receptor sites. Provides an alternative option for sedation. Used as the premed instead of diazepam or acepromazine, to help prevent transfusion reactions, when a patient has received or is anticipated to receive a transfusion. Use when a patient is undergoing surgery for a mast cell tumor instead of diazepam or acepromazine. Has a high first-pass effect when given orally. Only 40 to 60 percent will reach the systemic circulation, thus injections are more effective.
The following articles discuss the effects of butorphanol and other analgesics:
Diphenhydramine
1. Lascelles BDX, Roberston SA. Use of thermal threshold

response to evaluate the antinociceptive effects of butorphanol in cats. Am J Vet Res. 2004;65:1085-1089. 2. Ko JCH, Lange DN, Mandsager RE, Payton ME, Bowen C, Kamata A, et al. Effects of butorphanol and carprofen on the minimal alveolar concentration of isoflurane in dogs. J Am Vet Med Assoc. 2000;217:1025-1028. 3. Romans CW, Gordon WJ, Robinson DA, Evans R, Conzemius MG. Effect of postoperative analgesic protocol on limb function following onychectomy in cats. J Am Vet Med Assoc. 2005;227:89-93. 4. Gellasch KL, Kruse-Elliot KT, Osmond CS, Shih ANC, Bjorling DE. Comparison of transdermal administration of fentanyl versus intramuscular administration of butorphanol for analgesia after onychectomy in cats. J Am Vet Med Assoc. 2002;220:1020-1024. 5. Ilkiw JE, Pascoe PJ, Tripp LD. Effects of morphine, butorphanol, buprenorphine and U50488H on the minimum alveolar concentration of isoflurane in cats. Am J Vet Res. 2002;63:1198-1202.
Fentanyl patch
An opiate agonist at mu receptors. Onset of action is fairly long, taking up to six to 12 hours. Duration provides Fentanyl patch good long-term analgesic propertiesapproximately two to three days. 80 to 85 percent protein bound, highly lipophilic. Metabolized in the liver, with the majority of the drug excreted in the urine and a small percentage eliminated in the feces. Used in Orthopedic Protocol in conjunction with morphine. The goal is to use opioids for immediate period following orthopedic surgery, then transition the patient from opioids to nonsteroidal anti-inflammatories (NSAIDs) within two days and maintain the patient on NSAIDs thereafter as needed.
Diazepam
A benzodiazepine. Rapid onset of action. Duration of approximately six to eight hours. Highly protein bound. Metabolized in the liver to active metabolites that are excreted in the urine. Potentiates action of GABA resulting in neural and CNS depression. A sedative. A muscle relaxant. Anticonvulsantof great benefit in the Central Nervous System (CNS) Protocol as it will help to prevent seizures in
Diazepam
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As a transdermal delivery system, it takes approximately 12 hours to take effect, and in some patients, it may take 24 hours. The patch is best applied to a shaved area. Skin inflammation and temperature can affect absorption (i.e., increased warmth results in greater absorption and likelihood of toxicity). Patients ingesting the patch may get fentanyl toxicity. For small dogs and cats, the patch should not be cut, nor should a portion of a patch be covered. If the correct size patch for a Pet is not available as a full patch, do not use a fentanyl patch. Class II controlled substance. Follow DEA regulations regarding storage, usage and documentation.
Wait a full 30 minutes before deciding the first dose has been ineffective before administering more Telazol to achieve desired effect. Some Pets take up to 30 minutes to succumb to the effects.
INDUCTION AGENTS
Prior to anesthetizing the patient, verify that pre-anesthesia blood tests were completed within 48 hours prior to induction. Address any abnormalities found. If abnormalities are noted and anesthesia is necessary, choose the appropriate protocol.

Make sure premeds have had 30 minutes to take effect. If insufficient time is given, a much higher dose of induction agent will be required. Re-evaluate cardiovascular system after premeds have taken effect. Induction agents are used to facilitate intubation. Induction doses are administered carefully and to effect. Induction methods should provide a smooth and calm transition to unconsciousness. The induction phase is one of the two most common times when adverse anesthesia events occur, recovery being the other. It is important to monitor patients carefully during the induction phase to prevent occurrence of adverse events. See individual anesthesia protocols for appropriate induction agents. Mask induction is highly stressful and causes catecholamine release and tachycardia. Mask induction should only be used when specifically instructed by the protocol. Tank induction has special Occupational Safety and Health Administration (OSHA) restrictions in addition to being stressful for the Pet, so it is prohibited at Banfield.
Morphine
An opiate agonist. Good analgesic properties. Onset of action occurs within 15 to 60 minutes. Duration of approximately three to seven hours; half-life in dogs is approximately one hour; in cats approximately three hours.
Morphine
Absorbed rapidly after injected; concentrates in the kidney, liver and lungs; lower levels are found in the CNS. The maximum effect is reached four hours after administration. Only 30 to 40 percent protein bound. Metabolized in the liver, primarily by glucuronidation, so half-life in cats may be prolonged. Metabolites excreted by kidneys. Agonist at mu and kappa opioid receptors. Give intramuscularly (IM) ONLY. Respiratory depression, vomiting and histamine release can occur if given IV. Due to the sensitivity of dogs and cats to the emetic effects of morphine it should not be given after intra-abdominal procedures. The pressure created by the act of emesis may lead to postoperative complications. Used in the Orthopedic and Ear Protocols. Class II controlled substance. Follow DEA regulations regarding storage, usage and documentation.
Ketamine
Used as an induction agent for some exotic species. (See Anesthetic Considerations for Small Exotic Pets, page 95).
Telazol
See induction agents for complete information. Can be used as a premed in fractious Pets (except for brachycephalic dogs and cats). Dose is 0.5 to 2.0 mg/lb IM. Use low doses with debilitated or ill Pets. Maximum single dose is 100 mg.
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INDUCTION AGENTS (cont'd) Propofol

A hypnotic sedative. An alkylphenol derivative. Insoluble in water. Formulated as an emulsion. The emulsion components of soybean oil, ovolecithin and glycerol are media that allow bacterial growth, therefore, the product has limited shelf life after opening. Highly protein bound.
Wipe stopper with alcohol before withdrawals from the vial to decrease contamination. It is recommended to give 1/4 to 1/3 of the calculated dose as a bolus, assess patient, and give the rest as needed to allow for intubation. After induction, keep any remaining propofol in the syringe for the same patient. If the patient needs a small dose of agent during the transition from propofol to sevoflurane, it will be readily available. The average dose of propofol following premedication is 1 to 3 mg/lb, and 2 to 4 mg/lb if no premedication is administered. Healthy cats often require closer to 3 mg/lb with premeds; ill cats often require less.
Propofol
Metabolized in the liver to inactive metabolites that are excreted in the urine.
Telazol (Zolazepam and Tiletamine)

Similar to diazepam and ketamine but with greater synergism. Major uses include: Immobilizationroutine cases. Fractious Pet Protocol. IV induction when lipemia is present.
Telazol
Propofol has three main uses: (In the hospital, you will primarily use it for induction and immobilization. If you need it for other uses, please contact a medical director or advisor for further information.) 1. Induction agent. Prior to inhalant gas maintenance. Given at least 30 minutes after premeds. 2. Immobilization/chemical restraint. Examinations and diagnostic procedures. Radiology. 3. Anesthetic maintenance. When intubation is not possible (i.e., tracheoscopy or bronchoscopy). Status epilepticus that is refractory to diazepam or phenobarbital injections. Constant rate infusion: 0.1 to 0.25 mg/lb/min. Duration: five to 10 minutes. It is redistributed to adipose tissue fairly quickly after injection. Analgesia: only during unconsciousness. Side effects: apnea, cyanosis, hypotension, bradycardia (rate and dose dependent). Extravasation outside the vein causes NO tissue irritation. Because it contains no preservatives, the use of a single bottle of propofol is limited to one day. Once a bottle is opened, it is thrown away at the end of the day. With the potential for bacterial growth, it cannot be kept overnight. The product is not designed to be refrigerated or frozen, so this will not help extend the shelf life.
Induction for the Ear Protocol if no other health problems. Provides better immobilization during anesthesia. Zolazepam is similar to diazepam, which is a minor tranquilizer. Duration of action: one to two hours, dogs; three to four hours, cats. Tiletamine is a dissociative like ketamine. Duration of action: two to three hours, dogs; 1.5 to two hours, cats. In cats, the duration of effect of zolazepam exceeds that of tiletamine so that as the cat recovers there is a greater degree of tranquilization than anesthetization. In dogs, the duration of effect of tiletamine exceeds that of zolazepam so there is a lesser degree of tranquilization than anesthetization in this species. The total effect of Telazol in dogs is of shorter duration than in cats. Not an ideal choice for Pets with known cardiac disease. Pharmacokinetic data is limited. Ketamine, a similar drug, is only 50 percent protein bound. This is the safest drug in our pharmacy for the fractious Pet in the absence of information. (See Premedications, page 15.)
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INTUBATION
Choose an appropriately sized endotracheal (ET) tube (See Endotracheal tube selection, pages 37 and 38). During intubation, the PetNurse supports the patient in sternal recumbency, on its chest, with the head up. Measure ET tube so that it will reach only to the thoracic inlet. Mark this location on the tube and tie gauze around the spot. If using a stylet, ensure it does not protrude beyond the distal end of ET tube or through the murphy eye. Lubricate tube with K-Y Jelly. While supporting the patient, the PetNurse opens the patients mouth wide and gently pulls the tongue out (Figure 1.4). Using a laryngoscope to visualize the laryngeal folds, the doctor places the ET tube into the trachea. Some state laws will allow the doctor to train the PetNurse to do this. Once the tube is in place, palpate the end of the tube through the trachea to ensure the tip is just cranial to the thoracic inlet. Grip trachea with thumb and forefinger and slide tube in and out a few millimeters. You should be able to feel the end of the tube slide past your fingers. Auscultate all lung fields to detect and correct unintentional bronchial intubation; this will ensure proper placement and airflow. If inadequate airflow is noted, deflate the endotracheal tube cuff and back the tube out until good airflow is auscultated. Movement of the rebreathing bag is a good indicator of airflow as is ventilatory effort. If poor flow is noted, inspect the endotracheal tube for kinking. If mucus is noted in the oral cavity, inspect the endotracheal tube for a mucus plug. This may require extubation. Secure tube around the patients maxilla/nose or the back of head, using the gauze strip. A rubber band may be used for small dogs and cats. Figure 1.4: Intubating a Cat
The Cuff The cuff is an inflatable balloon-like device on the end of the ET tube designed to minimize the air space between the outer walls of the tube and the inner walls of the trachea, so that the patient cannot breathe around the tube and thus receive an inadequate or inappropriate amount of oxygen and anesthesia. Before using the ET tube, check the cuff for leaks as follows: Gently inflate the cuff using a syringe of air inserted at the end of the air line. Watch the cuff inflate. Over-inflation will destroy the cuff. Remove the syringe and gently squeeze the cuff to determine if there are any leaks. Once you have confirmed there are no leaks, deflate the cuff by reattaching the syringe and withdrawing the plunger to remove the air from the cuff. The cuff must be deflated before intubation. Once the patient is intubated, inflate the cuff as follows: Insert the syringe at the end of the air line. Inject air into the line; the cuff at the other end will inflate. Do not overfill the cuff as excessive pressure can injure the patients airway. Pressure-check the cuffthe cuff should restrict air flow at 18 to 20 cm H2O, and should leak before the pressure hits 25 cm H2O.
Intubation and airway management in cats

A cats larynx is very sensitive to mechanical stimulation, is easily irritated and can be damaged if mishandled. Laryngospasm is most likely to occur if forced intubation is attempted while the cat is too lightly anesthetized. Mild laryngospasms are bothersome; severe laryngospasms can result in death. Have the proper equipment ready to intubate before anesthetic induction. Have several sizes of endotracheal (ET) tubes handy. Using an appropriate stylet in flexible tubes is helpful. Use a laryngoscope to avoid having trouble visualizing the larynx. Make sure the cat is adequately anesthetized before attempting intubation. Attempting to intubate a cat in a light anesthetic plane is likely to cause coughing and laryngospasm. Simply increasing the depth of anesthesia will allow intubation in most cases. Use topical viscous lidocaine to desensitize the larynx. Do not use Cetacaine (benzocaine)it causes methemoglobinemia in cats. Dip the end of a Q-tip in topical lidocaine, as it works faster than using injectable lidocaine. If the viscous isnt available, place a few drops of injectable lidocaine on a Q-tip, gently swab the laryngeal area, wait 60 to 90 seconds, then attempt intubation. Avoid using too much lidocaine; it absorbs systemically and could cause toxicity.
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Extend the cats neck, pull the tongue forward, and open the mouth by pulling down on the jaw (NOT the tongue). Place the lubricated endotracheal tube just in front of the larynx with the bevel ventral. Without touching the arytenoids, wait for a breath, then gently insert the tube while rotating the tip. Tracheal damage can easily occur if you arent careful. Mucosal irritation can cause a severe cough after recovery. Tracheal lacerations can lead to subcutaneous (SC) emphysema, pneumomediastinum, pneumothorax and death. Most lacerations are caused by inappropriate use of stylets, improper lubrication, over-inflation of the cuff or twisting of the ET tube when repositioning the cat. Never allow stylets to extend beyond the tip of the ET tube. Listen for leaks before inflating the ET tube; if the ET tube is a tight fit, little to no cuff inflation is necessary. Using the manometer as a guide, only inflate to prevent a leak at a pressure of approximately 18 to 20 cm H20.
Brachycephalic breeds that wake up faster experience fewer airway maintenance difficulties. Premedications tend to decrease excitement during recovery.
OXYGEN FLOW RATES DURING ANESTHESIA Rebreathing circuit

Current anesthesia protocols call for a transition phase with oxygen flow rates of 3 L/min and sevoflurane level at 3 percent during the first three minutes of anesthesia when Pets are induced with propofol. This is because propofol is rapidly redistributed from the blood to tissues so the Pet will tend to wake rapidly after induction, resulting in a smooth transition from induction to maintenance anesthesia. These same settings are not neccessary with Telazol induction. Following the transition phase, oxygen flow rates are decreased to 1 to 1.5 L/min. In the majority of patients, higher oxygen flow rates are not necessary to maintain oxygen saturation greater than 94 percent. Higher oxygen flow rates vaporize sevoflurane at a faster rate, thus increasing the cost of anesthesia. Higher oxygen flow rates may also contribute to hypothermia, especially in small Pets.
Always disconnect the ET tube from the breathing system before repositioning the cat. Twisting of the tube in the airway can cause serious damage. If a patient laryngospasms and is in danger, place a large-gauge needle into the trachea percutaneously and administer pure oxygen until the swelling decreases.
MAINTENANCE AGENT Sevoflurane

Sevoflurane is a halogenated hydrocarbon (methyl-ethylether) with a lower solubility than isoflurane. This lower solubility allows for rapid changes in the depth of anesthesiait is quicker to get into trouble and out of trouble. This rapid change in anesthetic depth allows for more precise control, but also requires closer monitoring. It's much easier to have a patient extremely deep within a few minutes. The vaporizer at maintenance levels will normally be set between 2 percent and 3 percent, but may require higher or lower settings. The vaporizer setting and end-tidal sevoflurane concentration are slightly different. Patients that are ill or compromised will often need a vaporizer setting of less than 2 percent. The goal of gas anesthesia maintenance is to have the patient at the plane of anesthesia that is necessary at any given time. Sevoflurane allows the patient to be taken deeper during the painful part of a surgical procedure and then taken to a lesser plane of anesthesia for surgical closure. The end result is less risk to the patient. Return to full consciousness is generally rapid. This is especially important in brachycephalic breeds where airway compromise is prevalent. With consciousness comes airway protection.
Non-rebreathing circuit (Bain's)

Generally, flow rates around 3 L/minute will be needed for the duration of anesthesia.
ASSISTED VENTILATION
When assisted ventilation is necessary, it is important to deliver the correct inspiratory pressure to avoid adverse pulmonary function or complications: 12 to 15 cm H2O for small Pets and Pets with chronic pulmonary disease. 20 cm H2O for medium to large Pets. 25 cm H2O may be required for giant Pets. Ventilation should be delivered in a manner similar to normal respirationavoid holding inspiratory pressure. The manometer should return to zero between breaths when no pressure is in the bag. The pressure relief pop-off valve should be open when not assisting ventilation, and should only be closed to reach desired positive pressure during assisted ventilation. A patient under anesthesia who is breathing spontaneously should be bagged twice per minute, not to exceed the pressure listed above. This ensures full inflation of the entire lung field and helps reduce atelectasis.
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Patients that are not breathing spontaneously should have assisted ventilation at 10 to 12 breaths per minute, not to exceed the pressure listed above.
to remember that blood pressure is not an exact indicator of cardiac output or organ perfusion, but it will assist in determining cardiovascular function. Systolic, diastolic and mean arterial pressure (MAP) are all different values associated with blood pressure monitoring, all of which contribute to the bigger clinical picture of what is occurring within the patient. Systolic pressure is the measurement of the maximum arterial pressure during ventricular contraction (systole). Diastolic pressure is the measurement of the minimum arterial pressure during ventricular relaxation (diastole). MAP is the measurement of arterial pressure throughout one full cardiac cycle (one heartbeat). A patient's pulse is created by the difference in systolic and diastolic pressures. However, palpating the pulse does not provide information about the patient's MAP, which is the most important indicator of organ perfusion. There are several different methods for evaluting blood pressure: Direct measurements can be obtained by placing a catheter into an artery and connecting it to a transducer. This type of blood pressure monitoring provides accurate readings, but requires a high level of technical proficiency for placement. Indirect measurements are often obtained by using an inflatable cuff that detects blood flow after occlusion of a superficial artery. This technique requires less technical skill and poses less risk to the patient. Oscillometric measurement is a type of indirect measurement that detects periodic fluctuations that are produced by movement of the arterial wall. Inflation and deflation of the cuff are automated and most oscillometric devices will provide systolic, diastolic and MAP. Because this type of monitoring is based on fluctuations occurring underneath the cuff, there are several factors that can affect the accuracy of readings. The width of the cuff should be 40 percent of the circumference of the patient's limb. If the cuff is too large, readings will be low, and if the cuff is too small the readings will be high. The cuff should be placed on one of the limbs or at the base of the tail. It is important to keep the cuff at the same level as the heart, regardless of where it is placed. The hose connecting the cuff to the monitor should be free of kinks and kept from bouncing. The movement of the hose may be interpreted as fluctuations occurring during the blood pressure reading.
FLUID ADMINISTRATION
(See Fluid Therapy in Pets, page 91.) For healthy patients and hepatic and renal patients, 2.5 percent dextrose/0.45 percent NaCl may help reduce recovery time as hypoglycemia may result in prolonged recovery time. A shiver reflex is necessary for patients to warm themselves during recovery and dextrose is required for the shiver reflex to occur. The use of fluids containing dextrose is avoided in critical cases (cardiac, pulmonary, abdominal), as hyperglycemia is related to an increased risk of re-perfusion injury in the event of cardiac arrest. 0.9 percent NaCl fluid is preferred in these cases, as it does not contain additives that will interact with emergency drugs. If cardiac arrest occurs in other patients, switch to 0.9 percent NaCl fluids. Pulse oximeter readings are not affected by the administration of Oxyglobin (Hb200).
MONITORING
Death is a late sign of poor perfusion. Patients are not fine one minute and dead the next. Lee Tyner, DVM The importance of monitoring patients during anesthesia is to evaluate tissue perfusion. Anesthetics depress autonomic nervous system (ANS) function. The ANS maintains and manages perfusion. Monitor multiple systems for trends. See Anesthesia Monitoring and Emergency Protocol algorithm. The primary cause for crisis during or after anesthesia is the failure to notice a problem when it first occurs.
Three goals of monitoring

Anticipate complications. Recognize complications. Correct complications.
BLOOD PRESSURE
One of the ways to monitor organ perfusion is to look at the patient's blood pressure values. Patients who are anesthetized are placed at risk for hypotension due to depression of cardiac output as a result of inhaled and injectable anesthetics. Hypotension that is not addressed will compromise perfusion of the kidneys, heart and brain, leading to organ dysfunction. It is important
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Anesthetic depth and patient condition are dose-dependent. As anesthesia dosage increases, depth is enhanced and anesthesia safety margins decrease. Anesthetic depth is determined by skeletal muscle tone, selected reflexes (i.e., jaw tone, withdrawal) and central or ventral corneal position. Direct response to surgical stimulation is the most reliable method of determining depth of anesthesia. If uncertain about a patients anesthetic depth, assume they are too deep! The patient should be continuously monitored until it can maintain a sternal position (i.e., temperature, pulse, respiration (TPR), physical exam (PE) and level of consciousness are all normal), then should be checked at least every 15 to 30 minutes until ready for discharge (be sure to document monitoring in medical notes). The purpose of monitoring and documenting values is to look for trends and address them early.
signify desiccated CO2 absorbent, a calibration error in the sensor itself or the presence of water on the sensor windows. A normal waveform will have a sloped rise as gas is exhaled from the lungs. Abnormal waveforms can indicate esophageal intubation, disconnection of the breathing circuit, hypoventilation, hypotension or airway obstruction among many other situations. When monitoring capnography and ETCO2 in a patient, it is important to keep the larger clinical picture in mind. A change in ETCO2 may be the first indication of an event occurring within the patient, so when an abnormality is noted, the trends of all other vitals being monitored should be taken into consideration before making a decision to intervene.
END TIDAL CO2

Monitoring end-tidal carbon dioxide (ETCO2) and capnography also contributes to maintaining a clear picture of what is happening in the anesthetized patient. Both ETCO2 and capnograms provide information about patient ventilation, circulation and metabolism. ETCO2 is displayed as a value and indicates the amount of CO2 that is being exhaled and is indicative of the arterial CO2. A gradual rise in ETCO2 can signify hypoventilation and increases in body temperature. A sudden rise in ETCO2 may be due to release of a tourniquet, NaHCO3 administration or a sudden increase in blood pressure. A gradual decrease in ETCO2 can indicate a decreasing body temperature, hyperventilation and a decrease in lung perfusion. ETCO2 value dropping to zero can be caused by inadvertent extubation or disconnection of the breathing circuit, a defect in the CO2 analyzer or a kinked endotracheal tube. When the ETCO2 value suddenly drops, but not all the way to zero, this often indicates an obstruction in the airway or a leak in the system. An exponential decrease in ETCO2 values can indicate embolism, cardiac arrest, sudden hypotension and severe hyperventilation. The capnogram is a waveform that displays expired CO2 over time. This waveform validates the ETCO2 value and provides the opportunity to monitor trends in the patient's CO2 levels. The baseline of the capnogram should be at zero. If the baseline is above zero or begins to rise, this can
HYPOTHERMIA
Hypothermiabody temp below 98Fis common after 30 minutes of surgery and should actively be avoided and proactively managed to keep the Pets body temperature as close to normal as possible. Hypothermia prolongs recovery, increases stress and enhances depression; in turn, less anesthetic agent is required to maintain appropriate depth of anesthesia and if this is not recognized by decreasing the inhalant anesthetic, it can result in the patient becoming too deep. Indeed, for every degree body temperature falls below 100F, the anesthesia requirements decrease by approximately 5 percent. For example, if the vaporizer is set at 2.5 and the patient temperature drops from 100F to 98F, the anesthetic decrease is 2F x 5 percent = 10 percent. So a 2.5 vaporizer setting x 10 percent = 0.25 decrease. The anesthetic requirement, with all else being the same, results in a vaporizer setting of 2.25.
Signs of significant hypothermia

Cyanosis. Arrhythmias. Cool extremities. Decreased respiratory rate. Shivering, which increases oxygen and glucose consumption. Hypoglycemia and hypothermia can occur simultaneously, especially in pediatric or small Pets. If a hypothermic patient is NOT shivering, always check its blood glucose levels and correct any hypoglycemia that is noted.
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Preventing heat loss

It is best to be proactive and work to prevent heat loss in your patients by: Inserting insulating pads between the Pet and the surgical table or grate. An insulating pad is the best choice for preventing heat loss when a patient is on the surgery table. Heating pads and warm water blankets dont have enough surface area contact to warm the patient; they only slow heat loss. In addition, anesthetized patients placed on heating pads (electrical or warm water) while on the surgery table may develop thermal skin burns from the pressure/heat contact. The electric heating pad is not designed for use on the surgery table. However, it provides excellent supplemental heat for patients recovering in the kennel who are able to be repositioned every five to 10 minutes or are awake enough to move themselves. Administering warm IV fluids (IV line can be run through a bowl of warm water). Only clipping the area needed for surgery. Using warm surgical scrubs in only the necessary amount (do not drench the patient). Using only a minimal amount of alcohol during the surgical prep. Keeping the Pet covered (place towels over the nonsurgical fields). Keeping oxygen flow rates low to maximize the effects of warming in the rebreathing circuit (must be adequate to support proper oxygenation).
If an abnormality is noticed, always work to address the underlying cause while starting supportive measures. Should a patients pulse quality or oxygen saturation diminish, the delivery of oxygen and fluids should be increased. Should increased oxygen and fluid administration fail to improve the patients condition, then Neo-Synephrine, an alpha-1 agonist, is given intranasally. A pure alpha-1 adrenergic agent, if absorbed and circulated, will vasoconstrict arterioles without affecting cardiac output. If Neo-Synephrine does not result in improved pulse quality and oxygen saturation, ephedrine is administered IV. Ephedrine indirectly stimulates both alpha-1 and beta-1 agonist activity (causing vasoconstriction and increased cardiac output) by causing the release of norepinephrine. Norepinephrine also affects beta-2 adrenergic receptors, but to a much lesser degree. Dobutamine, a pure beta-1 agonist, is given IV as a slow drip to increase cardiac output, if the previous steps fail to improve pulse quality and oxygen saturation. Epinephrine is given IV as the last step; it is an agonist at alpha-1, beta-1 and beta-2 receptors.
Recovery
If patient (usually dog) has a rough recovery, use 0.025 mg/lb acepromazine (diluted) IV given slowly, to effect (max dose 1.5 mg Ace) or diazepam at 0.05 to 0.1mg/lb IV slowly, to effect, (maximum dose 5 mg); if unable to access IV, then administer Ace (0.025 mg/lb) IM or diazepam (0.1 mg/lb) IM. Continue monitoring TPR and pulse quality until patient is able to sit sternally and is fully alert; maintain pulse oximeter on the patient until the patient is fully awake. Monitoring the Pets oxygenation level while recovering lets you know if the patient needs supplemental oxygen while transitioning back to room air from 100 percent oxygen. Document this postoperative monitoring in medical record. See Monitoring section. Deflate the cuff on the endotracheal tube at the first sign of increased consciousness and untie the endotracheal tube from the muzzle. As the patient recovers, the jaw tension increases, and the patient will begin to swallow. As the patient begins to swallow or move its own jaw, remove the endotracheal tube. Once the patient is sternal and normothermic, the Pet may be moved to a kennel. If recovery appears to be slower than normal, check for hypothermia and hypoglycemia. Correct if present.
Two methods for warming patients

Surround the patient with warm air. Use a trash bag and cut a hole in the bottom of the bag for the head to protrude. In the open end of the bag, circulate warm air with a hair dryer. This provides warm air in contact with enough surface area to warm the patient. Caution: EKG clips conduct heat and cause burns. Use care to avoid heating of the EKG clips. Warm the inspired air. This can be accomplished by using a warm water trap added to the anesthesia machine or by shining a light bulb on the soda lime canister. Care must be taken to prevent the temperature of the soda lime from exceeding 100F; place thermometer strips on the canister in various locations to monitor canister temperature.
ANESTHESIA MONITORING AND EMERGENCY PROTOCOL ALGORITHM

Review the algorithm (See page 86), keeping in mind the discussion of the autonomic nervous system and the necessity of maintaining perfusion/oxygenation of tissues during general anesthesia.
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PAIN MANAGEMENT
Appropriate postoperative pain management is a significant and important part of any anesthetic procedure that causes pain or inflammation in the Pet. It is not appropriate to forego appropriate pain management for any reason. It is the attending doctors responsibility to ensure that appropriate pain management is employed (See Table 3, page 28). Appropriate intraoperative and postoperative pain management is paramount to a successful anesthetic procedure. Premedication with pain medications and postoperative anti-inflammatories is simply the start of pain management. Depending on the duration and extent of the procedure, it is important to recognize the signs of intraoperative pain such as increased heart rate, blood pressure, or respiratory rate that may need to be treated with a repeated dosage of butorphanol versus increasing the sevoflurane concentration. Butorphanol can typically be administered safely every one to four hours. Multimodal pain management provides the best results, begins prior to anesthesia and must continue until all inflammation and pain have resolved. Multimodal pain management simply means that you are addressing pain management in more than one manner and/or at more than one level in the pain pathway. The use of local blocks, nonsteroidal anti-inflammatory agents (NSAIDs), narcotics and dissociatives are all examples of pain medications that can be used together in various combinations to address pain management. The use of local blocks should be strongly considered as there is good evidence to show that if you can prevent the transmission of pain, you will have less pain from the procedure even after the local wears off. We strongly encourage the use of local blocks for the following procedures: Feline declaws. Dental extractions. Epidurals for hind limb orthopedic procedures. Our premedications are designed to work with our postoperative pain management drugs in a multimodal fashion. See the Banfield Protocols for specific postoperative pain management recommendations (See Section 2, page 49).
Our most commonly used drugs are as follows:
Buprenorphine (injectable)
A partial opiate agonist/antagonist. Onset of action within 30 to 60 minutes; dependent on route of administration. Duration of approximately six to 12 hours. Highly bound to plasma proteins (96 percent). Metabolized in the liver and eliminated mainly in the feces (70 percent), with 30 percent excreted in the urine. Partial mu agonist and antagonist on the kappa receptor. Provides management of moderate to severe pain. Analgesic effect created by the binding of opiate receptors in the CNS. Dogs: 0.002 to 0.009 mg/lb IM, IV or SC every six to 12 hours in dogs (transmucosal absorption in the dog is still under question and review). Cats: 0.002 to 0.005 mg/lb IM, IV, SC or transmucosally every six to 12 hours in cats.
Butorphanol (Torbugesic) injectable

Efficacious for mild to moderate pain. Intermediate duration of action. Well-tolerated by cats. Produces less respiratory depression than does morphine or oxymorphone. No histamine release. Can be repeated as needed postoperatively every one to four hours. Dog: 0.1 to 0.2 mg IM, SC, duration one to two hours. Cat: 0.1 to 0.2 mg IM, SC, duration one to four hours. Do not exceed 5 mg per dose to avoid dysphoria. Time to effect: ~ 15 to 30 minutes.
(Reference: Hellyer PW, Gaynor JS. Acute postsurgical pain in dogs and cats. Compendium on Continuing Education for the Practicing Veterinarian. Feb 1998;20(2)140-153.)
Butorphanol +/- diphenhydramine oral

Combine butorphanol injectable at dose of 0.1 to 0.2 mg/lb with cherry syrup or VAL syrup. Mixture may be administered postoperatively every four to six hours as needed for pain in dog and cat for one to two days. Dose frequency may need to be decreased if patient is inactive or lethargic. If greater sedation is desired, can add diphenhydramine injectable at a dose of 1.0 mg/lb per dose. Example: 25 lb dog. Butorphanol dose: 0.1 to 0.2 mg/lb x 25 lbs = 2.5 mg to 5 mg.
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Diphenhydramine dose: 25 mg per dose. Conversions: 1 tsp = 5 ml; 6 tsp = 1 oz; 1 oz = 30 ml; 4 oz = 120 ml. Injectable butorphanol: 10 mg/ml. Injectable diphenhydramine: 50 mg/ml. To make a 2-oz. bottle: 6 ml butorphanol (60 mg) + 6 ml diphenhydramine (300 mg) + 48 ml cherry syrup or VAL syrup = 60 ml of 1mg/ml butorphanol and 5 mg/ml diphenhydramine syrup. If you want butorphanol alone, substitute 6 mls of the VAL or cherry syrup for the 6 mls of diphenhydramine to keep the concentration of butorphanol the same. Dosage: Give 0.5 to 1 tsp (2.5 to 5 ml) of syrup q five hours as needed.
1.3 to 1.8 mg/lb PO once daily for post-operative pain management.
Etodolac (Etogesic) oral (dogs only)

Anti-inflammatory analgesic. Time to effect: ~ 2 hours. Long duration. Metabolized in the liver and excreted through the bile into the feces. Mild to moderate pain relief. Tolerated by dogs. Potent inhibitor of cyclo-oxygenase-2 while relatively sparing of cyclo-oxygenase-1. This provides inhibition of prostaglandins involved with pain and inflammation while sparing prostaglandins involved with cytoprotection of the GI and renal systems. Dogs may be more sensitive to renal injury if they are dehydrated or on diuretics. Do not use in the presence of renal disease or liver disease. Do not use with other NSAIDs or corticosteroids, or in patients with risk of bleeding. 5 to 7 mg/lb PO in dogs once daily for five to seven days. Do not give with preoperative medications, as it is highly protein bound.
Carprofen (Rimadyl) oral (dogs only)

Anti-inflammatory analgesic. Peak effect: ~ 1 to 3 hours. Long duration. Metabolized in the liver, with the majority (70 to 80 percent) eliminated in the feces and remainder eliminated in the urine. Mild to moderate pain relief. Tolerated by dogs. Potent inhibitor of cyclo-oxygenase, phospholipase A2 and prostaglandin synthesis. Do not use in the presence of renal disease and liver disease. Do not use with other NSAIDs or corticosteroids, or in patients with risk of bleeding. 2.0 mg/lb PO in dogs once daily or divided into two equal doses for five to seven days. Do not give preoperatively, as it is highly protein bound.
Ketoprofen (Ketofen) injectable

Anti-inflammatory analgesic. Mild to moderate pain relief. Long duration. Tolerated by dogs and cats. Potent inhibitor of prostaglandin synthesis. Do not use in the presence of renal disease, liver disease, hypovolemia or hypotension. Do not use with corticosteroids, or in patients with risk of bleeding. 0.9 mg/lb IV, IM, SC, (dog and cat) once (initial dose only). 0.45 mg/lb IM, SC, PO once daily starting next day for 48 hrs. Time to effect: ~ 45 minutes. Give near the end of surgery or postoperatively once you are confident there is no abnormal bleeding or hypotension. Do not give with preoperative medications, as it is highly protein bound.
Deracoxib (Deramaxx) (dogs only)

COX-2 selective NSAID. Reaches peak plasma concentration within two hours following administration. Duration is dependent on drug concentration and will last three hours at 1 mg/lb and up to 19 hours at 9 mg/lb. Highly protein bound (90 percent). Metabolized into four metabolites in the liver and eliminated with the feces. Inhibits prostaglandins that contribute to pain and inflammation by inhibiting COX-2. Provides management of post-operative pain, and treatment of pain associated with osteoarthritis. 0.45 to 0.9 mg/lb PO once daily to manage pain associated with osteoarthritis.
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Ketoprofen (Ketofen) oral

Mix injectable ketoprofen (100 mg/ml) with cherry syrup or VAL syrup and dose at 0.45 mg/lb q 24 h PO (dog and cat). For smaller or larger patients, the concentration of syrup can be changed to allow for easier dosing. Not recommended to be used for more than five days. Do not use with steroids. Ensure patient maintains normal water intake while using. Example: 20 lb dog. Ketoprofen dose: 20 lb x 0.45 mg/lb = 9 mg ketoprofen SID. Mix: 1 ml ketoprofen added to 9 ml cherry syrup or VAL syrup = 10 mg/ml/ketoprofen. Dose: 20 lb dog dosed at 0.9 ml of mix q 24 h PO.
Tramadol oral
Synthetic opiate agonist analgesic (not a federally scheduled drug). Onset of action is within 60 minutes. Mild to moderate pain relief. Moderate duration of action. Metabolized in the liver and excreted in the urine. Tolerated by dogs and cats. Synthetic mu-receptor opiate agonist and inhibitor of reuptake for both serotonin and norepinephrine. Use with caution with other central nervous system (CNS) depressants and in patients with history of seizures. Dose may need to be reduced in patients with hepatic or renal disease. Dogs: 1 to 2 mg/lb PO two to three times daily for five to seven days. Cats: 2 mg/lb PO twice daily for five to seven days. Can be used in conjunction with NSAIDs or corticosteroids.
Protocol to treat Ketoprofen overdose - See SmartHelp
Meloxicam oral
COX-2 preferential NSAID. Honey flavored base in two strengths: 0.5mg/ml 15ml (equivalent to 0.016 mg per drop); 1.5mg/ml 10 ml (equivalent to 0.05 mg per drop). Dogs: Meloxicam is well absorbed by dogs after oral administration and can be administered directly into the mouth or mixed with food. Food does not alter absorption. Recommended initial dose is 0.09 mg/lb the first day of treatment, and then subsequent doses of 0.045 mg/lb PO once per day. Cats: Meloxicam can also be used orally in cats, but it is considered off-label use of the product due to lack of efficacy and safety studies in the United States. Dosage schemes for cats for osteoarthritis and inflammation or chronic pain are as follows: The initial dose given should be 0.05 to 0.09 mg/ lb PO depending on the severity of the pain. This can then be followed by a daily dose of 0.02 mg/lb PO. Reaches peak plasma levels at seven to eight hours post administration. Duration of 24 hours. Highly protein bound (97 percent). Metabolized in the liver, mainly eliminated in the feces. Inhibits cyclo-oxygenase, phospholipase A2 and prostaglandin synthesis by preferentially inhibiting COX-2. Provides analgesic, anti-inflammatory and antipyretic effects similar to other NSAIDs. Provides control of pain and inflammation associated with osteoarthritis.
Clearance of NSAIDs Think. Make a good decision.

There may be situations where you need to switch from one NSAID to another in an attempt to improve antiinflammatory and analgesic efficacy. It is important to take into consideration how long the period of time following one NSAID administration is, before the administration of a different NSAID. Clinicians have empirically recommended various washout periods, ranging from 24 hours to seven days after use of an NSAID and before administration of another NSAID or a glucocorticoid. Although analysis of serum half-lives of the NSAIDs indicates that they would be cleared within eight to 12 hours, there is a prolonged clinical effect of analgesia for many of these medications. Therefore, a rule of thumb for washout is five to 10 half-lives following the first NSAID (See Table 2, page 27).
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Table 2: NSAIDS Washout Chart Product Aspirin Carprofen (Rimadyl) Deracoxib (Deramaxx) Etodolac (EtoGesic) Flunixin (Banamine) Ketoprofen (Ketofen) Meloxicam (Metacam) Phenylbutazone Piroxicam (Feldene) Tepoxaline (Zubrin) Est. serum half-life (hours) 7.5 - 12 5 - 8 (oral) 22 - 23 (injectable) 3 9.7 - 14.4 3.7 4-5 20-30 5X half-lives (days) 10 - 14 recommended 2 (oral) 5 (injectable) Next day 3 Next day Next day 7 10X half-lives (days) 10 - 14 recommended (aspirin triggering lipoxin) 4 (oral) 10 (injectable) 2 6 2 2
14
2.5 40 2-3
Next day 9 Next day
2 18 2
This table is a guideline for washout based on NSAID half-lives (wait at least five to 10 half-lives between NSAIDs).
Reference Dowers KL, Uhrig SR, Mama KR, Gaynor JS, Hellyer PW. Effect of short-term sequential administration of nonsteroidal anti-inflammatory drugs on the stomach and proximal portion of the duodenum in healthy dogs. AJVR. 2006;67(10):1794-1801.
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Table 3: Anesthesia Task Pain Chart Recommended Analgesic(s) Expected Level of Pain Severe to Excruciating Associated Surgical Procedure or Disease Process
Neurotic pain/central nervous system (CNS): nerve entrapment, cervical intervertebral disc disease (IVDD), herniations, severe inflammation, meningitis, CNS infarcts/tumors. Multiple fractures or fracture repair with extensive soft tissue injury, pathological fractures. Extensive inflammation: peritonitis, fasciitis, severe cellulitis. Postsurgical pain after extensive tissue injury or inflammation. Necrotizing pancreatitis. Necrotizing cholecystitis. Bone neoplasia.
(in addition to local or regional nerve blocks when appropriate)
This level of pain can kill.
Mulitmodal pain control including opioids (morphine, fentanyl) and nonsteroidal anti-inflammatory drugs (NSAIDs), where appropriate.
Moderate to Severe and Severe
(varies with degree of illness)
Musculoskeletal: osteoarthritis; acute polyarthritis; some intra-articular surgical procedures (i.e., large dogs, extensive manipulation); fracture repair; hypertrophic osteodystrophy; panosteitis; some dental extractions (multiple rooted teeth, some canine teeth, extensive handling or difficult removal, extensive soft tissue involvement); onychectomy. Soft tissue surgery: total ear canal ablation; post-laparotomy (extensive tissue handling or inflammation); post-thoracotomy; traumatic diaphragmatic hernia repair (associated with organ or extensive tissue injury); extensive mass removals; extensive soft tissue injury repair (extensive laceration repair, etc.). Peritonitis (i.e., bacterial, urine, bile, pancreatic). Early or resolving stages of soft tissue injuries/inflammation/disease. Capsular pain due to organomegaly (i.e., pyelonephritis, hepatitis, splenitis, splenic torsion). Mesenteric, gastric, testicular, or other torsions, hollow organ distention. Pleuritis; trauma (i.e., orthopedic, extensive soft tissue, head); thoracolumbar disk disease; rewarming after accidental hypothermia; frostbite; cancer pain; mucositis; thrombosis/ischemia (arterial or venous); aortic saddle thrombosis; ocular: corneal abrasion/ulceration, glaucoma, uveitis; reproductive tract: whelping/queening, mastitis.
Mulitmodal pain control including opioids (morphine, fentanyl for severe pain, butorphanol, tramadol, buprenorphine for moderate pain) and NSAIDs (where appropriate).
Moderate
Minimally invasive orthopedic procedures: extracapsular cruciate repair; external fixator placement for fracture repair; tail amputation; simple dental extractions (incisors, some small pre-molars, uncomplicated removal). Soft tissue surgery: laparotomy (short, minimal tissue manipulation or inflammation); uncomplicated inguinal hernia repair; diaphragmatic hernia repair (acute, simple, no organ injury); some external mass removals/laceration repairs (less extensive that noted above); ovariohysterectomy/castration (older or obese patients, or extensive tissue handling), enucleation. Some dental procedures (simple gingival flaps); some soft tissue injuries (less extensive than noted above); urethral obstruction; resolving pancreatitis, early or resolving surgical procedure; illness; injury.
Mulitmodal pain control including opioids (butorphanol, tramadol, buprenorphine) and NSAIDs (where appropriate).
Mild to Moderate
Soft tissue surgery: ovariohysterectomy/castration (young animals); some lacerations; lump removals; chest drains. Some dental procedures. Cystitis. Otitis. Early or resolving surgical procedure, illness, injury.
(varies with degree of illness or tissue manipulation/ injury)
For moderate pain: mulitmodal pain control including opioids (butorphanol, tramadol, buprenorphine) and NSAIDs (where appropriate). For mild pain: butorphanol, buprenorphine or NSAIDs. Butorphanol, tramadol, buprenorphine (low end dose) or NSAIDs.
Mild
Early, resolving, or simple involvement of surgical procedure, illness, or injury.
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DENTAL NERVE BLOCKS Why use local dental blocks

Oral procedures HURT! Analgesia should be a part of every anesthetic protocol because it is good medicine, humane and decreases anesthetic induction and maintenance drug dosages.
Bupivacaine Fairly slow onset: 10 to 20 minutes. Long duration of action: approximately three to eight hours. Maximum dose per dog is 1.0 mg/lb and 0.5 mg/lb in the cat. Highly protein bound (95 percent). Metabolized in the liver and excreted through the urine. Blocks the generation of and conduction of nerve impulses. Provides analgesia for local nerve blocks. Should not be administered intravenously. More toxic to the heart than lidocaine. Mixture of Lidocaine and Bupivacaine Practice recommendation is to use either lidocaine or bupivacaine, and not the mixture. Toxicities are additive, so use half dose of each. Moderate onset of action: eight to 10 minutes. Moderate duration of action: two to four hours. Dose: Dog: Lidocaine 2 percent at 0.5 mg/lb mixed with bupivacaine 0.5 percent at 0.5 mg/lb. Cat: Lidocaine 2 percent at 0.5 mg/lb mixed with bupivicaine 0.5 percent at 0.25 mg/lb.
When to use local dental blocks

Dental extractions. Painful oral surgery (e.g., oronasal fistula repair). Tumor removal. Fracture repair.
How to use local blocks

As part of balanced analgesiait enhances pre-emptive and multimodal pain control. Local anesthetics block painful impulses to the spinal cord and decrease wind-up. Local anesthetics will wear off, therefore the concurrent use of other agents is required to provide long-term multimodal pain management. Can volume dilute with sterile saline if necessary.
Commonly used local blocks for oral pain

Infraorbital. Maxillary. Middle mental. Inferior alveolar.
Local anesthetic agents

Lidocaine Quick onset: two to five minutes. Fairly short duration of action: approximately 90 minutes. Standard dosage is 1 mg/lb. Do not exceed maximum dose per dog or cat of 2 mg/lb. Maximum dose per dog or cat is 2 mg/lb. 60 to 80 percent protein bound depending on concentration. Rapidly metabolized in the liver to active metabolites and excreted by the kidneys. Stabilizes neuronal membranes which inhibits the initiation and conduction of impulses thereby creating a local anesthetic action.
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DENTAL NERVE BLOCK TECHNIQUES

Most dental procedures produce strong sensory stimuli that affect general anesthesia requirements and postoperative recovery. Dental nerve blocks interrupt these sensory stimuli locally and should be a component of overall pain management. Regional dental nerve blocks can decrease the concentration of inhalant anesthesia required, which reduces adverse side effects, such as hypotension, bradycardia and hypoventilation.1 In addition, dental nerve blocks ease the patients recovery from anesthesia because adverse side effects, such as hypertension, tachycardia and tachypnea, are also minimized postoperatively because of decreased oral pain.2 Local anesthetics completely block sensory nerve transmission and prevent secondary (central) pain sensitization. For this reason, local blocks are often used in conjunction with other injectable and systemic pain medications.3 Perioperative pain management is required for tissue injury resulting from noxious stimuli and a subsequent decreased pain threshold at the surgical site. Analgesics given preoperatively and intraoperatively are often insufficient because of the ongoing postoperative inflammatory reaction involving the injured hard and soft tissue. The resultant inflammatory mediator release can cause peripheral and central sensitization.4 Practitioners should consider a multimodal pain management approach to prevent pain hypersensitivity.4 The benefits of implementing multimodal pain management for dental and oral surgery, specifically dental blocks, include:
Owners expect effective pain management. Pets often are discharged the same day after dental procedures, and owners want their Pets to be as alert and painfree as possible. Pets recover faster and with fewer complications.5 The minimum alveolar concentration required for inhalant anesthetics is decreased, therefore reducing anesthesia complications and improving safety.1 They eliminate the pain perception, decrease anesthesia levels and result in a smoother anesthesia experience.6 Local blocks continue to provide analgesia in the postoperative period, keeping the Pet comfortable while using fewer systemic pain medications.7,8 Signs of pain after dental procedures, such as rough recoveries, vocalization, restlessness, pawing at the mouth, behavior changes, inappetence and depression, are minimized when regional oral nerve blocks are used.9 Many dental surgical procedures produce strong stimulation, and Pets undergoing them often manifest variable depths of general anesthesia due to poor or inadequate analgesic administration.10 Common dental and oral surgical procedures for which dental nerve blocks are indicated include: Surgical and nonsurgical extractions. Advanced periodontal treatments, such as root planing, periodontal debridement and periodontal flap surgery. Oral trauma that involves lacerations of the lips, gums and tongue; foreign bodies; and jaw fractures that require soft and hard tissue surgical intervention. Incisional and excisional biopsies. Soft- and hard-tissue oral surgery, such as oronasal fistula repair, palatal surgery, maxillectomies, mandibulectomies and reconstruction surgery.
Anatomy of oral nerves

Sensory innervation to the oral structures arises from the trigeminal nerve. In the maxilla, the upper teeth, soft and hard tissue and palate are innervated by the maxillary nerve that enters the maxillary foramen and infraorbital canal from the sphenopalatine fossa. The maxillary nerve branches into the infraorbital nerve, which in turn branches into the caudal, middle and rostral superior alveolar nerves. In the mandible, the lower teeth and soft and hard tissues are innervated by the mandibular nerve. The mandibular nerve branches into the lingual nerve just before it enters the mandibular foramen and provides sensory innervation to the tongue and the inferior alveolar nerve; this nerve branches into the rostral, middle and caudal mental nerves, which provide sensory innervation to the lower molars, premolars, canines, incisors and soft and hard tissues of the rostral mandible.
Anatomy of a tooth.
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Figure 1.5
Figure 1.6
Location of the infraorbital nerve block. Figure 1.7
Infraorbital nerve block on a dog skull. Figure 1.8
Infraorbital nerve block in a dog. Figure 1.9
Infraorbital nerve block on a cat skull. Figure 1.10
Infraorbital nerve block in a cat.
Maxillary nerve block on a dog skull.
The infraorbital, maxillary, middle mental foramen and inferior alveolar (mandibular) blocks are the most common regional dental nerve blocks used in veterinary medicine. There are several variations on the technique, including intraoral and extraoral positioning of the needle. Gentle insertion of the needle into the soft tissue or foramen will minimize tissue trauma. Once inserted in the proper location, aspirate to ensure that there is no vascular access and then inject slowly. If aspiration yields blood, remove
the needle and syringe and start over with a clean needle and syringe. This article will emphasize only intraoral techniques.
Administration of nerve blocks

Materials and equipment needed for dental nerve blocks are minimal and include bupivacaine (0.5 percent); 1 ml syringes; 25-gauge, 5/8-inch needles; surgical scrub; and a dog and cat skull to help you locate the foramina.
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Figure 1.11
Figure 1.12
Maxillary nerve block in a dog. Figure 1.13
Location of the middle mental nerve block. Figure 1.14
Middle mental nerve block on a dog skull. Figure 1.15
Middle mental nerve block in a dog. Figure 1.16
Location of the inferior alveolar nerve block.
Inferior alveolar nerve block on a dog skull.
Bupivacaine (0.5 percent) is the agent of choice for these procedures. Its onset of action is 10 to 15 minutes, and the duration of action is three to eight hours.1,2 It offers a higher degree of sensory block than other injectable agents, such as lidocaine (which is ideal for sensory nerves of the head) with less tissue irritation.9 Epinephrine (1:200,000) can be added to the bupivacaine to counteract the vasodilation effects; it causes vasoconstriction and,
therefore, aids in homeostasis and prolongs the dental blocks effect.3-5 Bupivacaine is more toxic than lidocaine to the heart, so the lowest possible dose is used (i.e., do not exceed 2 mg/kg for a total cumulative dose in dogs and 1 mg/kg for a total cumulative dose in cats during any given procedure).1,2,4 Generally, the dose per site is 0.5 to 1.0 ml in dogs and 0.2 to 0.3 ml in cats. Keep in mind that in a small dog (e.g., 3 kg), you will need to reduce
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the recommended dose of 0.5 ml per site so you dont exceed the total cumulative dose. Some veterinary hospitals have developed charts with weight ranges correlating to the total cumulative dose.
Figure 1.17
Infraorbital nerve block

Infraorbital nerve blocks affect the maxillary incisors; canines; and the first, second and third premolars as well as the soft and hard tissues rostral to the upper fourth premolars. The nerve can be palpated as an indentation at the bony ridge in the maxilla dorsal to the distal root of the third maxillary premolar in dogs. It is halfway between a line drawn from the apex of the canine tooth to the dorsal border of the zygomatic arch. In cats, the infraorbital foramen is palpated as a bony ridge dorsal to the second premolar just ventral to the eye, where the zygomatic arch meets the maxilla. In cats, the infraorbital block affects all the teeth on the ipsilateral side where the block is done. Once the location is identified, clean the area with surgical scrub and palpate the infraorbital foramen. Insert the needle to the hub through the buccal mucosa in a caudal direction parallel to the dental arcade, into the entrance of the foramen. Aspirate and then inject slowly (Figures 1.5 to 1.9, page 31).
Inferior alveolar nerve block in a dog. Figure 1.18
Maxillary nerve block

This block affects the maxillary fourth premolar, upper molars and the soft and hard tissue caudal to the maxillary fourth premolars, including the hard and soft palate. This block mimics a splash blockyou are not actually entering a foramen as you do with the infraorbital block, but you rely on anatomical direction to affect the maxillary nerve by injecting in the area where the nerve branches around the upper molars and fourth premolar. This block is only used in dogs. Clean the area with surgical scrub and insert the needle to the hub into the area of soft tissue just caudal to the last molar at a 30 to 45 degree angle with the dental arcade. Aspirate and then inject slowly (Figures 1.10 and 1.11, pages 31 and 32).
Middle mental nerve block

Inferior alveolar nerve block on a cat skull. Figure 1.19
The middle mental block affects primarily the mandibular incisors and surrounding soft tissue.11,12 The middle mental foramen is the largest of the three mental foramina and is the one used most often. It is located and can be palpated ventral to the mesial root of the lower second premolar, just caudal to the mandibular labial frenulum. In cats and small-breed dogs, the middle mental foramen is difficult to palpate; therefore, the inferior alveolar nerve block is used in those cases. Once identified, clean the area with surgical scrub, insert the needle into the submucosa in a rostral to caudal direction and advance it into the middle mental foramen. Aspirate and inject slowly. In most dogs, the needle will not penetrate completely to the hub as it does with the infraorbital dental block (Figures 1.12 to 1.14, page 32).
Inferior alveolar nerve block

Inferior alveolar nerve block in a cat.
The inferior alveolar, or mandibular, block affects all the teeth in the mandible, including the soft and hard tissues. If the local anesthetic infiltrates in a more lingual caudal direction, the
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tongue may be affected; therefore, it is important to make sure the needle is directed toward the caudal ramus of the mandible when inserting to prevent the bupivacaine from anesthetizing the tongue. The mandibular foramen is located two-thirds of the distance from the last molar to the angular process. The foramen is 1/2 to 1 inch from the ventral surface of the mandible in dogs and 1/4 inch from the ventral surface of the mandible in cats. Palpate the angular process extraorally (as the most caudal and ventral projection of the mandible) and the mandibular foramen intraorally with a forefinger. Insert the needle just caudal to the last molar in a direction towards the angular process, and advance the needle along the lingual surface of the mandible adjacent to the mandibular foramen. Aspirate and inject slowly (Figures 1.15 to 1.19, pages 32 and 33).
References 1. Holmstrom SE, Frost P, Eisner ER. Veterinary Dental Techniques. Philadelphia, Pa: W.B. Saunders. 1998;492-493. 2. Rochette J. Local anesthetic nerve blocks and oral analgesia. In: Proceedings, 26th World Congress World Small Anim Vet Assoc. 2001. 3. Lemke KA, Dawson SD. Local and regional anesthesia. Vet Clin North Am Small Anim Prac. 2000;30:839-842. 4. Beckman BW. Pathophysiology and management of surgical and chronic oral pain in dogs and cats. J Vet Dent. 2006;23:5059. 5. Lantz G. Regional anesthesia for dentistry and oral surgery. J Vet Dent. 2003;20:81-86. 6. Ruess-Lamky, H. Administering dental nerve blocks. J Am Anim Hosp Assoc. 2007;43:298-305. 7. Haws IJ. Local dental anesthesia. In: Proceedings, 13th Annual Vet Dental Forum. October 1999. 8. Kaurich MJ, Otomo-Corgel J, Nagy FJ. Comparison of postoperative bupivacaine with lidocaine on pain and analgesic use following periodontal surgery. J West Soc Periodontal Abstr. 1997;45:5-8. 9. Robinson, Elaine P. Pain management for dentistry and oral surgery: Pain management symposium. In: Proceedings, Am Anim Hosp Assoc Conf. March 2002. 10. Duke T. Dental anaesthesia and special care of the dental patient. In: BSAVA Manual of Small Animal Dentistry. 2nd ed. BSAVA, Cheltenham UK. 1995;27-34. 11. Klima L, Hansen D, Goldstein G. University of Minnesota Veterinary Medical Center. Unpublished data. 2007. 12. Robinson E. University of Minnesota College of Veterinary Medicine. Personal communication, 2002. 13. Pogrel MA, Thamby S. Permanent nerve involvement resulting from inferior alveolar nerve blocks. J Am Dent Assoc. 2000;131:901-907. 14. Younessi OJ, Punnia-Moorth A. Cardiovascular effects of bupivacaine and the role of this agent in preemptive dental analgesia. Anesth Prog. 1999;46:56-62.
Discussion
Regional dental nerve blocks are relatively safe when used correctly. Complications resulting from oral nerve blocks have been described in human dentistry; however, the incidence is extremely low.13 Toxic doses of bupivacaine have been reported to cause cardiovascular toxicity and death in people, although this is also very rare.14 Even though these complications are uncommon in Pets, practitioners still need to ensure correct dosing, choose an appropriate needle size and length, identify appropriate locations, insert and advance the needle gently to avoid unnecessary soft tissue trauma and aspirate before injecting the bupivacaine. With practice and proper training, dental nerve blocks are inexpensive to perform and easy to learn. They will significantly improve Pet care and be a valuable addition to your pain management armamentarium for your dental and oral surgical procedures.
Dr. Mullings and Shelby
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TECHNIQUES FOR EPIDURAL ANALGESIA

For epidural analgesia, patients are typically sedated or anesthetized and placed in sternal or lateral recumbency. Sternal recumbency facilitates the hanging drop technique whereas lateral recumbency facilitates positioning of animals with fractures. Next, the cranial edges of the wings of the ilia are palpated (Figures 1.20 and 1.21). A line connecting these two points typically overlies the vertebral body of L7. Just caudal to this line an indentation can be felt which corresponds to the lumbosacral junction. Location can be verified by palpating the dorsal spinous process of the seventh lumbar vertebra rostral to this indentation. Once located, a 10 cm by 10 cm area of hair directly over the lumbosacral junction is clipped and the skin is surgically prepared.
Figure 1.22
Figure 1.20
Figure 1.23
Figure 1.21
Needle insertion is made directly over the depression formed by the lumbosacral junction with the needle initially positioned perpendicular to the skin (Figures 1.22 and 1.23). It is important the stylet is correctly positioned within the needle to prevent transplantation of skin into the epidural space. When using the hanging drop technique, the stylet is removed after penetrating the skin and placed on a sterile area (typically the paper glove liner).
Then, a few drops of solution are placed in the hub of the needle until a meniscus is formed. The needle is slowly advanced until it encounters bone or punctures the ligamentum flavum. If bone is struck, the needle is withdrawn to the subcutaneous tissue and redirected. If the ligamentum flavum is punctured and the needle tip enters the epidural space, fluid will typically flow from the hub of the needle into the space (Figures 1.24a and 1.24b, page 36).
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Figure 1.24a
Figure 1.25
Materials Needed Spinal needle: 2.5- to 3.5-inches long. Sterile gloves. Drugs and Dosages
Keep the total epidural injection volume below 0.05 ml/lb. Preservative-free morphine (1.0 mg/ml). Dose: 0.05 to 0.1mg/lb, no need to dilute, volume is generally appropriate when using preservative-free morphine. Duration: eight to 24 hours. Minimal systemic effects; bradycardia can occur. For further information on epidurals, epidural medications and dosages, please call your medical director or the medical advisors.
Figure 1.24b
If the epidural is being performed while the Pet is in lateral recumbency, the stylet is left in the needle until a characteristic pop is felt as the ligamentum flavum is punctured. With both techniques, following insertion and removal of the stylet, the needle is observed for flow of cerebral spinal fluid or blood. Once the tip of the needle is confirmed to be in the epidural space, the syringe is attached to the hub of the epidural needle and a slow injection of the analgesic agent is begun (Figure 1.25). Observation of the lack of compression of a small (1 ml) air bubble in the syringe helps to ensure that there is no resistance to injection. Following injection the needle is withdrawn and the surgical site is placed ventrally in order to facilitate the movement of analgesic drug to the correct side of the spinal cord. Other signs indicating correct needle placement may include twitching of the tail muscles and a change of respiratory pattern during injection. If blood flows out of the needle, it can be withdrawn and flushed, then reinserted (with the stylet in place). If cerebrospinal fluid flows out of the needle and the decision is made to inject analgesic into the subarachnoid space, the dose volume should be reduced by at least 50 percent.
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ANESTHESIA EQUIPMENT
This section reviews specific recommendations for various anesthetic-related items. It is the responsibility of the attending doctor to ensure that the proper anesthesia equipment is chosen for each Pet and that the anesthesia equipment is in good working order before a procedure is started (See Figure 1.26, Anesthesia System Flow Chart, page 44).
Recommended IV catheter size

Wt. (lbs) > 35 lbs 20 to 35 lbs 4 to 19 lbs < 4 lbs Wt. (kg) > 15.9 kg 9.0 to 15.9 kg 1.80 to 8.6 kg < 1.8 kg Catheter size 18 gauge 20 to 18 gauge 22 to 20 gauge 24 to 20 gauge
Anesthetic rebreathing bag size

Wt. (lbs) 0 to 10 lbs 10.1 to 20 lbs 20.1 to 60 lbs 60.1 to 120 lbs 120.1 to 160 lbs Wt. (kg) 0 to 4.5 kg 4.6 to 9.0 kg 9.1 to 27.2 kg 27.3 to 54.4 kg 54.5 to 72.6 kg Bag size 1/2-liter bag 1-liter bag 2-liter bag 3-liter bag 5-liter bag
IV catheters
Endotracheal tube selection

The tube sizes indicated in this section are approximate. The largest tube that will fit easily and not irritate or traumatize the trachea is recommended. Cuffs should be tested for integrity before use. Do not over-inflate either in the patient or when leak testing outside of the patient. Tubes must be clean and in good condition. Endotracheal tubes should be rinsed after every use with a mild detergent or antiseptic (antibacterial hand soap or dilute chlorhexidine). Always ensure the cuff is inflated during the washing process to remove any debris on the cuff. Endotracheal cleaning brushes MUST be used to clean the internal surfaces of the tube as well. ALL cleaning residue MUST be rinsed off completely with water. Residual chlorhexidine has been associated with epithelial ulceration and chemical burns in the oral cavity and trachea of cats exposed to it. Be careful and thoroughly remove any detergent residue. After cleaning, deflate the cuff again and hang to dry.
Endotracheal tubes Anesthetic rebreathing bags
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ET tube size for dogs

Wt. (lbs) 0 to 4.4 4.5 to 8.8 8.9 to 15.4 15.5 to 19.8 19.9 to 26.4 26.5 to 30.8 30.9 to 44.0 44.1 to 66.0 66.1 to 88.0 Wt. (kg) 0 to 2 2.1 to 4 4.1 to 7 7.1 to 9 9.1 to 12 12.1 to 14 14.1 to 20 20.1 to 30 30.1 to 40 Tube size (mm) 5 6 7 8 8 9 10 12 14
Non-rebreathing circuit
flow rate should never be below 2 liters per minute when using a non-rebreathing system. There are three parts of the non-rebreathing circuit that need to be connected:
ET tube size for cats

Wt. (lbs) Wt. (kg) 0 to 1 1.1 to 2 2.1 to 5 5.1 to 5.5 Tube size (mm) 3 4 5 5
0 to 2.2 2.3 to 4.4 4.5 to 11.0 11.06 to 12.12
The patient end is the portion of the breathing circuit that is connected to the endotracheal tube or mask on the patient. The quick-disconnect is the part that connects to the anesthesia machine. This connection can be made to include or exclude the heater/humidifier. To include the heater/humidifier, attach the quick-disconnect part of the non-rebreathing circuit to the red female end of the tubing coming from the heater/humidifier. This will allow for heated/humidified oxygen and anesthetic gas to be delivered to the patient. To exclude the heater/humidifier, the quick-disconnect part of the non-rebreathing circuit should be inserted into the female end of the tubing that is coming from the vaporizer on the anesthesia cart. The pop-off valve on the non-rebreathing circuit should be inserted into the scavenger hose that is a part of the hospitals anesthesia scavenger system. Always verify that the pop-off valves on the non-rebreathing circuit are open before connecting to the scavenger system (See page 41).
Universal F circuit: rebreathing circuit
Breathing circuit guidelines

0 to 4 lb use non-rebreathing circuit 4 to 20 lb use pediatric (pink) rebreathing circuit > 20 lbs use adult (blue) rebreathing circuit
Always trace the flow of gas through the anesthesia machine to ensure that the non-rebreathing circuit has been set up properly.
Care of circuits and cleaning

Rebreathing circuits and non-rebreathing circuits should at least be cleaned daily in a dilute chlorhexidine solution. Tubing and bags should be soaked for no more than 10 minutes and then thoroughly and completely rinsed in water. Remove as much of the water as possible from the circuits and bags by using centrifugal force. Hang circuits to dry after anesthesia. Do not leave them attached to the anesthesia machine. Replace circuits every six months.
Non-rebreathing circuit
The non-rebreathing (Baines, Modified Jackson-Rees) circuit should be utilized on Pets that are 4 pounds or less. It is important to remember that the non-rebreathing circuit is a semi-closed system and does not utilize the CO2 absorbent. In order to prevent rebreathing of the CO2, the flow rate of oxygen needs to be higher than the patients respiratory volume. Therefore, the oxygen
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Oxygen cylinders
There are various sizes of oxygen cylinders in our practice. Once you know how much oxygen each tank holds, you can quickly calculate the approximate minutes of oxygen remaining in a partial tank. A full tank, regardless of size, is pressurized to 2000 psi (pounds per square inch). The small E tanks hold 600 liters of oxygen. If you have no backup E tanks in your hospital, you should not attempt surgery with less than 500 psi remaining in your tank. The watermelon tanks that fit into the back of the anesthesia cart hold 1200 liters of oxygen. With 500 psi, you have 300 liters of oxygen. The large H tanks hold 7000 liters of oxygen, and at 500 PSI (1/4 left), 1750 liters of oxygen remains. If you are running a flow rate of 1 L/minute, you have adequate oxygen delivery for 1750 minutes or 29 hours of anesthesia time.
Soda lime canister sticker
Soda lime canisters

An important step in anesthesia is to ensure that all anesthesia equipment is in proper working order and all of the supplies needed for anesthesia are present and up-to-date. One of the most important maintenance items on the anesthesia machine is the absorber assembly, which contains the canister for the CO2 absorbent (soda lime, Carbolime, Soda lime canister Amsorb, etc.) which removes carbon dioxide from the rebreathing circuit. The canister filled with absorbent is a common area for malfunctions in the anesthetic system and is a source of resistance during ventilation. It is removed regularly to change the CO2 absorbent and leaks can result from failure to create a tight seal when replacing the canister. Proper packing of the canister is necessary to prevent flow of gases over a single pathway inside, which creates excessive dead space. Gently shake the canister when filling it with soda lime to prevent loose packing and reduce channeling. Packing too tightly causes dust formation and increases resistance to ventilation. It is important to understand the function of the chemical absorbent. Depending on the fresh gas inflow, all or part of the exhaled carbon dioxide may be absorbed chemically. Chemical absorption of carbon dioxide enables a lower flow of fresh gas, reduces waste of inhalant anesthetics and oxygen, and minimizes the cost of anesthesia. Calcium hydroxide is the primary component of CO2 absorbents.
When checking a rebreathing system, always make sure that the CO2 absorbent is functional. Whereas fresh granules will be soft enough to crush, the exhausted granules are chemically altered and are hard. Once the granules become hardened, they will no longer absorb carbon dioxide and should be thrown away and replaced immediately. Indicators of pH are added to the absorbents so that as chemical reactions happen, the color of the granules changes. Most CO2 absorbents will turn from white to violet as the granules become exhausted. However, not all absorbents will maintain the violet color and the granules will revert back to white after a period of time. This does not indicate that the granules are safe to continue using. CO2 absorbents should be changed routinely and you should not wait for color change to replace absorbent. CO2 absorbents can become exhausted or desiccated when they are used beyond their capacity to hold carbon dioxide. Desiccation occurs when the absorbent becomes "dried out" whether from being utilized within the breathing circuit, sitting in the canister during periods when it is not in use, or if it is left unsealed in storage. When the granules are exhausted, carbon dioxide is not effectively removed from the rebreathing system, increasing the potential for hypercapnia. Hypercapnia leads to respiratory acidosis, and is also associated with sympathetic stimulation and cardiac arrhythmias that can lead to cardiac arrest. High levels of carbon dioxide can depress the central nervous system and have anesthetic effects. Another risk related to continued use of exhausted or desiccated CO2 absorbent is that dangerous levels of carbon monoxide gas and compound-A may be generated within the anesthesia system. These chemicals are released through a reaction that occurs between the absorbent and the anesthetic agent (sevoflurane). These reactions are typically seen when absorbents that contain NaOH and/or KOH are still used after they have become desiccated. Routinely changing the CO2 absorbent will help prevent this reaction from occurring. The CO2 absorbent should be changed based on anesthesia time. The following are guidelines based on the type of canister and amount of absorbent each canister holds. Please note that these
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figures are general guidelines only. The tidal volume of the patient is the determining factor; i.e., the larger the patient, the more carbon dioxide is produced and the faster the granules may be exhausted. Note: When pouring the absorbent into the canister, be careful not to get any in the center tube of the canister. Granules in the tube have the potential to enter the breathing circuit and the patient's airway. Most carts are equipped with the LEI Medical soda lime canisters. The VASCO (big fat) soda lime canisters are in some hospitals. Both are 1800 to 1850 cc and hold approximately one full 3-pound bag of absorbent. The absorbent has an expected life of 10 to 12 hours of anesthesia time or four weeks maximum exposure to room air. If you are unsure of how long the absorbent has been in use, check the consistency of the granules before using. Remember that the absorbent MUST be changed every 30 days, even if the color has not changed or the maximum anesthesia time has not been reached. In an effort to ensure that absorbent is changed in the appropriate time frame, each hospital receives a roll of 3 inch by 5 inch stickers to place on the absorbent canister. For each 15 minutes of anesthesia, one box is marked off. When the maximum amount of anesthesia time has been reached: The sticker is removed. The CO2 absorbent is changed. A new sticker is placed on the canister.
Solution: Evacuation system must be hooked up and adjusted properly. One end of 22 mm translucent white corrugated tubing attaches to the fitting in the ceiling, the other end attaches to the waste gas interface valve on the machine. Note: Do not connect 22 mm tubing from the ceiling directly to the pop-off valve or bag bleed valve! One end of the 19 mm Evacuation system evacuation, blue corrugated tubing attaches to either the pop-off valve on the rebreathing head or the bag bleed valve on the non-rebreathing system; the other end attaches to the waste gas interface valve on the machine. The ceiling adjustment handle, if your hospital is equipped with one, must be in the proper position to attain the proper negative pressure. This is at approximately a 45-degree angle (adjustments may be needed). Newer hospitals will not have an adjustment handle because the new waste gas interface, as noted in the photo, has an auto-regulation feature. If the waste gas interface valve is bypassed and the negative pressure from the evacuation system in the ceiling is applied directly to the anesthesia systems pop-off valve or bag bleed valve, the anesthetic procedure will be compromised. All Banfield hospitals should have a scavenger system. This system has been installed for the safe and complete removal of exhaled anesthesia gases generated during a surgical procedure. It is utilized in conjunction with the anesthesia machine. If you have an F-Air Canister and not a fan-style system, contact the CTS Facilities Hotline (ext. 5566). The scavenger unit is a UL-approved, custom-made exhaust fan housed in a 12-inch by 12-inch by 6-inch stainless steel box. This box is mounted above the ceiling tile in your hospital. It has been designed to draw in exhaled anesthesia gases and then expel those gases through a pipe in the roof of the building to the outside. The system itself consists of preset balancing valvesgate valves with a 1 diameter copper or white-painted pipe extending seven to 18 inches below itcoming down out of the ceiling in the surgery and treatment rooms. The clear plastic tubing that comes with the anesthesia machine connects from the anesthesia machine to the end of the balancing valve pipe. The balancing valves are connected above the ceiling tile in both rooms to a series of horizontal 3-inch copper piping, which is connected directly to the scavenger unit intake opening. Once the exhaled gases are drawn up through the balancing valve and piped into the unit, they are expelled into a 3-inch copper pipe leading up through the roof to the outside.
Safety pressure relief valve
Safety pressure relief valve

This valve is designed to stay open and can only shut when it is forcefully pressed down (See Pop-off Valve Functional Settings, page 41).
Evacuation system
If the active waste gas evacuation (scavenger) system is out of balance, anesthetic gases will follow the path of least resistance. If negative pressure is applied to the pop-off valve on the rebreathing head or the bag bleed valve on the non-rebreathing system, the patient may not be getting the proper dose of anesthetic.
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Pop-off Valve Functional Settings

Normal Operation
Screw-down pop-off valve open with push-button valve up.
Screw-down pop-off valve in open position.
In this position, the system is fully open and gas will pass freely. The manometer should read 0 with slight fluctuations during respiration. Squeezing the rebreathing bag should not create pressure in the system.
High Pressure Leak Check

Screw-down pop-off valve closed with push-button valve depressed.
In this position, the system is completely sealed and very high pressures can be obtained. This allows a high pressure check for system leaks. This position should never be used with a patient connected to the system. The screw-down pop-off valve should be opened after the high pressure leak check is completed.
Manual Ventilation
Screw-down pop-off valve open with push-button valve depressed.
In this position, the system is closed but it will leak at pressures of 20 to 25 cm H2O. This allows enough pressure to manually ventilate the patient without risking excessive pressure which can cause pulmonary damage and death.
User Error Safety
Screw-down pop-off valve closed with push-button valve open.
In this position, the system is partially closed but will leak at 0.5 cm H2O. This will not cause injury to the patient but depressing the push-button valve to ventilate the patient would allow excessive pressure and could injure the patient. This setting is designed to stop patient deaths associated with leaving the pop-off value closed but it is not recommended for normal operation.
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The scavenger unit is commonly located above the ceiling tile, in close proximity to the surgery room balancing valve. Call CTS Facilities Hotline (ext. 5566) for exact location. The scavenger unit is either plugged into a 110-watt electrical outlet or wired directly into an electrical box above the ceiling tile. This unit is turned on and off by a lighted wall switch commonly located inside or directly outside the surgery room. If the switch in your hospital is not a lighted one, please contact CTS Facilities Hotline for assistance. All scavenger units are equipped with a fusible link to prevent motor damage or tripping the electrical circuit. It is very important to turn off the scavenger unit when not in use. This unit was not designed to run continuously and, if left on, the life of the unit will be severely compromised. Older hospitals may have a scavenger unit located below the ceiling tile in the maintenance room. This unit is turned on and off by means of a toggle switch located on the unit itself. This units piping system above the ceiling is the same as all others.
A low-pressure failure of the regulator may result in one or more of the following: Improper or insufficient oxygen flush. Improper or insufficient oxygen delivered to patient. Failure of oxygen to pass through the regulator. Solution: If any one of the above conditions exists, replace oxygen regulator. Call CTS Facilities Hotline (ext. 5566) before proceeding.
Please keep in mind many new associates do not know what a scavenger system is, what it does and where the on-off switch is located. Use the label printer to make a Scavenger label to place on the on-off switch cover plate for easy recognition.
Manometer
Manometer
The needle on the manometer gauge should be at zero. The re-zero screw is located at the 12 oclock position under the crystal manometer cover. Remove the cover by turning counter clockwise. Adjust the screw mechanism until needle is zeroed. Replace manometer cover. If the manometer will not re-zero, or if needle will not deflect proper pressure, it should be replaced. If the manometer cover is cracked, broken or missing, it should be replaced.
Oxygen regulator
Regulator
The oxygen regulator is a medical grade, preset, non-adjustable regulator designed to reduce oxygen tank pressure from approximately 2100 psi, when full, to approximately 50 psi. The oxygen regulator can fail, resulting in pressure being too high or too low. A high-pressure failure of the regulator may result in one or more of the following: Failure of the oxygen quick-disconnects. Failure of the oxygen check valves in dual gas supply. Failure of black tubing. Failure of oxygen flush. Oxygen leak from regulator.
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Vaporizer and anesthesia machine service

Vaporizer service: Because sevoflurane is a relatively clean anesthetic, LEI Medical recommends that sevoflurane vaporizers be professionally cleaned and calibrated every two to three years. Two years after the initial cleaning and calibration date, LEI Medical will perform the following: Leak test the vaporizer. Output test of the vaporizer using Lamtec 605 infrared spectrophotometer or Riken analysis. A written report on the status of the vaporizer. Fill new vaporizers with sevoflurane and let sit for 24 hours to charge the wick in the vaporizer. After 24 hours, check sevoflurane levels in the vaporizer and refill as needed.
Anesthesia machine service: After two years use in the hospital, the entire anesthesia device will be serviced. The service will include, but isnt limited to, the following: Replace all black tubing. Replace all seals. Replace top canister gasket. Replace bottom canister gasket. Replace dome O rings (two each). Replace downtube O ring. Leak test high pressure system. Leak test low pressure system. Inspect pop-off valve pressure. Inspect waste gas interface device. Re-zero manometer.
Install mechanical stop oxygen flow control assembly, if not previously upgraded. Adjust existing mechanical stop oxygen flow control assembly if necessary. Inspect all components for proper fit, alignment, adjustment and operation. Disposable items will not be inspected or replaced at the two-year service. It is up to individual hospitals to ensure that their rebreathing sets, rebreathing bags and non-rebreathing systems are in proper condition for use.
Vaporizer
PAGE 43
Figure 1.26: Anesthesia System Flow Chart
PAGE 44
Dr. Darnell
PAGE 45
TROUBLE SHOOTING GUIDE

Note: If you have any questions, please contact your medical director or medical advisor at ext. 7800. Problem Cant keep patient downvaporizer at 4 percent or higher and patient is still waking up Diagnosis & Solution 1. Check for right bronchus intubation (extremely common). Endotracheal tube that enters the right bronchus limits anesthesia gas to one lobe of the lung. The vaporizer concentration must be higher to reach the same plane of anesthesia. Back out the endotracheal tube. 2. Check for improper evacuation system setup (extremely common). The scavenger system has too much suction and thus pulls anesthesia through the system. Make sure the scavenger system is connected to the scavenger interface system. This will look like a black box on the back of the anesthesia machine. The older style will be the size of a food can that contains a flipper. Make certain the flipper is fully open. To test the suction level of the scavenger fan, determine if the scavenger drop tubes have negative air pressure present at the opening. A very slight intake of air should be felt with the hand; or, hold a tissue to the opening and watch to ensure that the tissue is being gently drawn into the scavenger tube. (Do not allow the tissue to be drawn into the tube.) 3. Check for leak in system (common). 4. Check to make sure vaporizer is working and it is not empty (uncommon). Leaks Windex cleaner can be used to determine leaks on both the high-pressure and low-pressure side. Small bubbles less than 1 mm in diameter are acceptable. Large obvious bubbles are not acceptable. 1. High-pressure side leaks may or may not influence anesthesia. A small to moderate oxygen leak on high pressure will not affect performance of the vaporizer if oxygen flowmeter is supplied enough oxygen to read minimum 500 cc per minute flow. High-pressure leak results in waste of oxygen. A large leak, which precludes proper use of oxygen flowmeter, will affect anesthesia. It does not affect exposure of surgical personnel to inhalant anesthetic. 2. Low-pressure side leaks usually influence anesthesia. The larger the leak, the bigger the problem. With positive pressure within the breathing circle, when the patient exhales, anesthetic gases could come out into the room and expose surgical personnel. With negative pressure within the breathing circle, when the patient inhales, a large enough leak can draw in room air, thus diluting the concentration of anesthetic within the breathing circle. Patients dose of anesthetic is reduced and may become light.
Oxygen will not flow Too much pressure in breathing circle, or bag filling up too much
Check to see if oxygen tank is not turned on or is empty. Check oxygen flow rate as it may be too high. Normal rate is 1 to 1.5 L/min. Check for obstruction in system.
PAGE 46
Problem Vaporizer not workingrare
Diagnosis & Solution When vaporizers fail, they usually fail on the low side. It is very seldom that vaporizers fail on the high side, but it can happen. Though it is rare, it is possible that the vaporizer output is not accurate within acceptable limits. The system is serviced every two years and requires no routine maintenance in between. Before sending vaporizer in for service, check a number of parameters: First, check evacuation issues noted on the previous page. Second, check for leaks in the system. If evacuation issues and leaks are addressed and those systems are functioning properly, check the following: Ensure vaporizer is full of anesthetic. Ensure vaporizer fill cap is tightened down. Ensure vaporizer drain is tightened down. New vaporizers require 24 hours for the wick in the system to fill. Refill after the first 24 hours to make sure the system is fully charged. Is it a leak on the high pressure side? High pressure part of system is from the oxygen tank to the back of the flowmeter. Test for high pressure leak: Can you hear it? Spray Windex on fittings; if it bubbles, you have a leak. Never spray petroleum products on the oxygen system. Turn off oxygen flowmeter. Turn on oxygen tank. Watch oxygen tank pressure gauge on regulator. When needle on gauge is stable, turn off oxygen tank. If needle drops, you have a leak. The faster the needle drops, the bigger the leak. Possible sources of leak: Oxygen hose nut not tight. Solution: Tighten with crescent wrench. Oxygen flowmeter flow control assembly stuck in open position. Float (ball) in flowtube will not go to zero. The float may be stuck in flowmeter such that it is perceived that oxygen is flowing, when it is not. Debris in the flowmeter may be causing it to fail. Solution: Replace oxygen flow control assembly. Oxygen flush seal defective (very rare). Oxygen will leak past oxygen flush valve and dilute the concentration of anesthetic in the breathing circle. Solution: Replace entire oxygen flowmeter and flush assembly (rail system), or replace oxygen flush only in Compact-W. Loose fitting on back of flowmeter (rare). Solution: Tighten fitting with crescent wrench. Faulty check valve in dual gas supply (very rare). Solution: Replace check valve. Is leak on the low pressure side? Low pressure part of system is from the oxygen flowmeter control to end of Y on rebreathing head or elbow on non-rebreathing system. Perform the 10-second leak test. Possible sources of leak: Cracked lid in the soda lime canister (rare). Remove canister and lid and inspect lid for cracks. Solution: If lid is broken, cracked or chipped, replace lid assembly. Cracked canister. Inspect canister for cracks, looking for chips out of top and bottom rim where canister seats against gaskets (top and bottom). Solution: If canister is broken, cracked or chipped, replace canister. Crack in black tubing (rare). Inspect all black tubing for cracks, especially where tubing connects to hose barb fittings. Solution: If cracked tubing is found, replace entire length of tubing between each hose barb (remove tube, measure length, order appropriate length and replace), or, if crack is at hose barb fitting, remove hose, snip-off cracked portion and replace tube on hose barb.
PAGE 47
Problem Vaporizer not workingrare (cont'd)
Diagnosis & Solution Gasket (seal) at top and bottom of canister defective (possible). Inspect gaskets, top and bottom, for defects, dents, holes or carbon dioxide absorbing material. Gaskets should have a smooth surface without holes or dents. Check to see if carbon dioxide absorbing material is on the gasket. Solution: Clean off with plain water. If dents or holes or gasket has imperfections and will not seal then replace it. Order gasket (with O rings) kit. Replace all O rings and gaskets. Dome O rings. Inspect O rings for cracks, unscrew dome counterclockwise. Solution: If cracked, worn or defective, replace O ring. Order gasket kit. Replace all O rings and gaskets. Inlet and outlet adaptors on vaporizer (rare). Inspect inlet and outlet adaptors. Solution: Push adaptors onto vaporizer manifold to ensure tight seal. Common outlet. Inspect for cracks. Solution: If cracked, replace. Pop-off valve: Inspect area adjacent to pop-off valve for leaks (rare). Spray Windex at base of pop-off and block which houses pop-off. Solution: If leak is at base of pop-off, remove valve, use Teflon tape on threads and reinstall or, if leak is where pop-off valve mounting block joins to rebreathing head, replace rebreathing head. LEI Medical will replace rebreathing head block at no charge.
Pop-off valve. If pop-off valve has too much resistance, the rebreathing bag will fill, like a balloon, and the manometer will read higher than 3 to 4 cm of water pressure. Solution: Remove defective pop-off valve and install new pop-off valve. This service is provided at no charge, parts and freight. Pop-off valve. If pop-off valve has too little resistance, press valve until bag fills to proper fullness. Rebreathing bag (very frequent). Inspect rebreathing bag for holes, cracks and leaks. Porous tape will not stop a leak in a rebreathing bag. Solution: If bag is cracked, has holes or in any fashion lacks integrity, remove and replace with new rebreathing bag. Rebreathing hoses. Inspect rebreathing hoses for holes, cracks and leaks. Windex can be used for this purpose. Look closely at collars, Y-piece and where tubing joins collars. Solution: If corrugated tubing comes off collars easily, or if collars are missing entirely, discard tubing; if cracks appear at any point on rebreathing hoses, discard entire set. Do not try to replace broken fitting and replace with new. Oxygen will not flow or will not shut off Check non-mechanical stop-flow control (identified by a green plastic knob). Oxygen flow control assembly, found on earlier models, may be damaged. Over-tightening of oxygen flow control assembly results in damage to seat (where oxygen can leak past seat so that oxygen flow cannot shut off) or damage to needle valve (where needle valve can break off in seat which prevents the flow of oxygenknob and shaft continue to turn without oxygen flowing). If oxygen flush does not work, check to ensure that oxygen tank is on. Open tank valve by several turns. If oxygen flush and oxygen flowmeter do not work and tank is on, the regulator needs to be replaced or the oxygen tank needs to be replaced. Solution: Try another oxygen tank, if problems persist, change out regulator. If non-mechanical stop-flow control is deemed defective, it will be upgraded to a mechanical stop-flow control. If mechanical stop oxygen flow control assemblyidentified by green decal in center of silver knobis leaking (float does not come to rest at zero on the bottom of flow tube), the float may be stuck in flowmeter such that it is perceived that oxygen is flowing, but it is not. There may be debris in the flowmeter, causing it to fail. Solution: Remove the old flow control assembly and install new mechanical stop oxygen flow control assembly.
PAGE 48
Dr. Darnell and Jacquelin
Banfield Protocols
PRE-ANESTHETIC EVALUATION
All anesthesia protocols begin with a thorough patient history and physical examinationtwo critical steps in determining anesthetic risk. Why is this important? If you talk to clients, most, if not all, are very concerned about anesthetic risk. Even when their Pet appears healthy and the procedure is routine, clients want to be accurately informed of all risks. The majority of clients view their Pets as family members. According to the American Animal Hospital Association, 70 percent of Pet owners think of their Pets as children. Caring clients will avoid unnecessary risk. How do we best manage risk, assuring our clients, and ourselves, that we are doing everything possible to maximize patient safety? Using a systematic approach to pre-anesthetic patient evaluation is one essential step that, as part of an entire anesthetic system, has improved outcomes in our hospitals. The goals of a preanesthetic medical assessment are: Decrease morbidity and mortality with anesthesia. Determine the health status of a patient to minimize the risk of adverse events. Increase quality of care. Promote a problem-oriented approach to the procedures. Earn clients trust by ensuring their Pets safety and well-being. Provide baseline test results for future health care when applicable.
Section 2:
Banfield Protocols
Gathering information
The pre-anesthetic evaluation answers three questions: 1. Is the patient in the best possible condition or optimal health to undergo anesthesia? 2. Does the patient have a concurrent condition that should be addressed before the anesthetic procedure? 3. Does the health status or concurrent medication influence the anesthetic event, or delay or even cancel the procedure? The most important step of the pre-anesthetic examination is to accurately determine the patients health status. The pre-anesthetic evaluation is critical in minimizing the risk of morbidity and mortality and enabling the clinician to anticipate and possibly prevent potential complications during anesthesia. Proper assessment of a patients health, use of the safest anesthetic agents, and diligent monitoring and support of perfusion allow most procedures to be done with reasonable safety and produce the desired outcome. Appropriate anesthetic protocol and support of perfusion require understanding of the overall objectives of anesthesia and surgery. Evaluating the patient may reveal reasons to delay, cancel or reschedule the procedure until the Pet is stable. This will also allow time for additional testing, to obtain more information on
Banfield Protocols
PAGE 49
Anesthesia Decision Protocol
the Pets health or, if necessary, find a more experienced team to manage the high-risk patient. We believe a standardized, systematic approach is the best method to minimize risk. Consistency eliminates confusion that may occur in busy hospitals with multiple doctors using different protocols. A consistent protocol also permits analysis and aids in the establishment of best practices. An evidence-based approach shows that some protocols are safer than others, and objective data further defines and improves patient care.
Evaluation of history, physical examination, CBC and biochemical profile
Are there abnormalities to address?
NO
Perform procedure with anesthesia as planned.
YES Postpone procedure until abnormalities are addressed and patient is stabilized.
Is the procedure elective?
Another goal of pre-anesthetic testing is the establishment of baseline data. Despite practitioners efforts, client compliance with pre-anesthetic testing is still an issue. In many cases, collecting the pre-operative blood sample may be the only opportunity to determine baseline clinical pathologic data. Practitioners and clients should not underestimate the value of establishing a biochemical and hematologic baseline for patients. Charting trends over time is one of the best opportunities for early diagnosis and treatment of disease.
YES
Evaluating pre-anesthetic patients

A complete patient evaluationperformed before any anesthetic procedureshould consider signalment, medical history, physical examination findings and laboratory data. A step-by-step approach helps you detect potential complications and take action to prevent them (See Anesthesia Decision Protocol). Because the Pets health status and disease history are critical factors in determining the appropriate anesthetic protocol (See Banfield Anesthesia Protocol, page 51), evaluation involves more than performing a battery of tests. It requires using the information to determine the safest method if anesthesia is appropriate. A Pets signalment may warrant special consideration, as age, sex and breed are equally important elements to the pre-anesthetic assessment. A thorough medical history is particularly important as it may reveal previous disease and anesthetic complications, concurrent medications or other facts, such as a recent meal, that may impact procedures. The veterinary team also needs to document preventive care treatments such as vaccinations, parasite control, dental care and disease screening tests. If you find preventive care deficiencies, take steps to correct them before performing an elective procedure. If the procedure cannot be postponed, avoid administering vaccinations and deworming medications until the patient fully recovers from anesthesia. It is also important to inform all participating associates of every procedure being performed on the patient, as well as any medical history that could lead to an anesthetic complication. This ensures that the entire team has received the same information, which minimizes the chance of miscommunication during anesthesia.
NO
Banfield Protocols
Is there an immediate emergency?*
YES
Proceed as carefully and quickly as possible.
NO Try to stabilize the patient as quickly as possible (i.e., fluids, pain management, antibiotics, hot/cold therapy) and proceed.
Is this an emergency?
YES
NO Determine the best anesthesia protocol for the patient and proceed.
Is the Pets condition chronic and stable?
YES
NO
Determine what additional diagnostics are needed, begin appropriate therapy, and stabilize condition before proceeding with anesthesia.
Physical examination
Before any anesthetic procedure, conduct a thorough and deliberate physical examination. Record your findings in the patients medical record. When possible, resolve any issues before anesthetizing the Pet. A detailed evaluation of the cardiovascular and pulmonary systems is vital, as all anesthetic drugs depress cardiovascular and pulmonary function to some extent. The liver and kidneys also need specific assessment because of their role in metabolizing and eliminating anesthetic drugs. Again, any findings that are not within normal limits should be evaluated to determine if it is more appropriate to postpone the anesthetic event and work up the abnormality or to go forward with anesthesia. You may need to adjust the Anesthetic Protocol to ensure the Pets safety.
*An immediate emergency is when a patient cannot breathe or is bleeding from a major vessel and needs to be under anesthesia in less than 15 minutes.
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Banfield Protocols
Banfield Anesthesia Protocol
History
Fractious Pet?
YES
Fractious Pet Protocol
NO
Evaluate Blood Work
Physical Exam
Normal?
YES
Healthy Pet Protocol
NO
Pediatric Protocol
Lipemia Protocol
Hepatic Protocol
Renal Protocol
Post-Renal Protocol
Cardiac Protocol
CNS/Eye Globe Protocol
Feline Declaw Protocol
Orthopedic Protocol
Pulmonary Protocol
Obesity Protocol
Ear Protocol
Abdominal Protocol
Emergency Protocol
Stable Diabetic Protocol
Banfield Protocols
Postoperative Pain Management
Our practice uses a five-step approach in conjunction with a full physical examination before any anesthetic procedure to assess cardiovascular function and the Pets overall health. 1. Monitor capillary refill time, femoral pulse to heart rate ratio, pulse quality and heart rate. These parameters are key to evaluating perfusion before anesthesia. Adequate perfusion is vital to a successful anesthetic outcome. 2. Evaluate mucus membrane color for evidence of anemia, hyperemia (consider sepsis, hyperthermia or polycythemia), icterus or cyanosis. 3. Auscultate the heart. In young patients, a murmur may indicate a congenital heart abnormality or a physiological murmur. Generally, congenital heart defects pose a considerable risk for an adverse anesthetic event. Such patients should be considered high-risk and undergo anesthetic procedures only at a practice equipped to address these special needs. In adults, it is important to know if this is a new finding or if there is evidence of disease progression or signs of heart failure. If any concerns exist, a cardiac workup should be completed before anesthesia, if possible. 4. Auscultate the entire lung field to ensure normal sounds, airflow, oxygenation and ventilation. In any patient with respiratory symptoms, the physical examination is vital to determine the potential origin of the problem. As a general
approach, in patients with nasal discharge, the reason can be due to nasal or non-nasal disease. In patients with a cough, this can be due to disease of the airways, lungs or heart, or a combination of both. If respiratory noises were heard without a stethoscope, consider upper airway or nasal disease. Rapid respiration may be a result of non-respiratory conditions such as fever, acidosis or fear. According to the timing, inspiratory distress suggests upper airway or pleural space disease; expiratory distress suggests lower airway disease; shallow respiration suggests pleural space disease; and labored or deep respiration suggests upper airway obstruction. In cats, an expiratory wheeze may be due to bronchial spasm. 5. Evaluate the patients temperature for hypothermia or hyperthermia. Both are important, and the cause needs to be identified, corrected or appropriately addressed before anesthesia. This approach allows accurate evaluation of the Pets condition and helps detect abnormal findings. When problems are recognized, the protocol provides guidelines for proceeding with the anesthetic procedure.
Anesthesia cycle
To ensure safety, we recommend following the Anesthesia Cycle Protocol (See page 52), which provides step-by-step guidelines to follow during anesthesiafrom checking anesthesia equipment to patient observation following the procedure.
Banfield Protocols
PAGE 51
Anesthesia Cycle
Check Anesthesia Equipment*
Fractious Pet? - Telazol Protocol Review Medical Records, Perform PE, Draw Blood, & Place IV Cath
Evaluate Patient/Cardiovascular System**
Administer Induction Agent
Review Blood Test Results**
Attach Patient to Anesthesia Machine
Select Anesthesia Protocol
Attach Monitors
Select and Administer Premeds***
Evaluate Patient/Cardiovascular System
Wait 30 minutes for Premed Effect
Banfield Protocols
Discontinue Sevoflurane
Continue Oxygen for 3-5 Minutes Evaluate Patient/Cardiovascular System
Perform Surgical Prep and Move Patient
Evaluate Patient/Cardiovascular System
Phase 4
Monitor Continuously Until Patient Sternal and TRP WNL Record Anesthesia in Medical Records Using Anesthesia Stamp***** Update Soda Lime Hour Usage
Evaluate and Document Patient Anesthesia Monitoring Parameters Every 5-10 Minutes Adjust Anesthesia Based on Patient Needs
Evaluate Patient Temp Every 15-30 min****
Observe Patient for Minimum of 2 Hours
* All anesthesia equipment should be checked and working properly. Check anesthesia machine for leaks and ensure the remaining hour usage for soda lime meets or exceeds expected procedure time. ** Abnormalities should be evaluated and corrected prior to anesthesia, then documented in patient file. *** If patient is apparently healthy and may be difficult to handle a second time, healthy Pet premeds may be given at the time blood is drawn and catheter placed; if abnormalities are discovered on blood work, anesthesia should be delayed for at least 24 hours.
**** If temperature is low, actively warm patient using warm IV fluids and warm inhaled air. ***** Indicate rebreathing vs. non-rebreathing system; initial and maintenance oxygen flow rate and sevoflurane percentage; pulse oximeter readings; endotracheal (ET) tube size; drug doses (in mg or ml (mg/ml) and routes; temperature, pulse, respiration (TPR); (pre-induction, intra-op, postop, and pre-release); fluid type and rate; anesthesia and recovery time.
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Banfield Protocols
Phase 3
Remove ET Tube When Patient Swallows
Perform Procedure
Phase 2
Phase 1
Review & Document PE Findings**
Place Endotracheal Tube & Secure
Banfield Protocols
Dr. Marshall and Pee Wee
Banfield Protocols
PAGE 53
Canine/Feline Anesthesia Physical Examination
Evaluate History & drug therapy Bleeding disorders Hyperthermia Anesthesia problems Shunts Myopathies Pre-existing organ compromise
Patient
Weigh
Fractious Pet: Goal is to immobilize, obtain blood sample, place IV catheter, and perform examination/patient evaluation immediately. Immobilizing agent should serve as premed or induction agent. See Fractious Pet Protocol.
Complete physical examination, internal organ screen, CBC with differential.
Banfield Protocols
1 Capillary Fill Time <2 sec = Normal: Proceed w/ exam.
2 Mucus Membrane Color Pink: Normal; proceed w/ exam. Abnormal color: Evaluate HCT & Hgb. If normal, proceed w/ exam.
3 Auscultate Heart If normal, proceed w/exam.
4 Auscultate Lungs
Normal Air Movement Proceed w/ examination Abnormal: (no movement, non-compliant, dry/moist rales). Postpone if possible and make diagnosis; otherwise utilize a Pulmonary Protocol.
5 Temperature
Murmur* Present, See details page 55.
Hypothermia (<99F) Give warm 2.5% dextrose in 0.45% NaCl IV & warm Pet. If no improvement, postpone anesthesia and look for other cause.
Evaluate Femoral Pulse Rate/Heart Rate Ratio Ratio 1 : 1 = Normal: Proceed w/ exam. Ratio < 1 : 1 = Abnormal: Evaluate ECG and go to Cardiac Protocol.
Young Pets Consider congenital heart problem or physiologic murmur.
Evaluate Pulse Quality Firm & steady = proceed Abnormal = Evaluate ECG and go to a Cardiac Protocol.
Perform exercise tolerance test. ** Physiologic murmur should resolve.
Mature Pets Suspect acquired cardiac disease. Evaluate cardiac function & proceed to a Cardiac Protocol.
YES
Is the Pet obese?
NO
Hyperthermia (>103F) Check WBC count. If elevated, postpone anesthesia (if possible). Otherwise, give IV 0.9% NaCl and IV cefazolin only. Proceed to appropriate protocol.
Normal Heart Rate Values (awake Pet) Small dog: 100 to 140 Medium dog: 80 to 140 Large dog: 60 to 100 Cat: 120 to 160 If HR less than above, perform ECG and go to a Cardiac Protocol. With normal ECG, give glycopyrrolate 0.005 mg/lb (max of 0.4 mg) and reassess. If HR greater than above & no glycopyrrolate or atropine has been given, evaluate ECG and go to a Cardiac Protocol & R/O reasons for tachycardia (pain, anxiety, hypotension, anemia, etc.)
If ejection/systolic murmur present, consider stenosis or other congenital cardiac abnormality. Refer unless emergency. If emergency, cautiously proceed with a Cardiac Protocol.
Proceed with a Pulmonary Protocol.
Proceed with examination.
For Hyperthermic (not febrile) patients Acepromazine: 0.025 mg/lb (max of 1.5 mg) SC. Butorphanol: 0.1-0.2 mg/lb (max 5 mg) SC, IV uids. If no temp change, look for underlying cause and address prior to anesthesia as appropriate. If temp normal, go to Healthy Pet Protocol but use NO additional premeds.
**Exercise tolerence test: Perform ECG and immediately walk dog vigorously for 10 minutes. Recheck ECG. Normal = heart rate increase is less than 25% of pre-walk HR and returns to normal within 5 minutes.
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Banfield Protocols
Canine/Feline Anesthesia Physical Examination (cont'd) *Murmur Present
ultrasound and treat the patient accordingly. If the patient has no clinical signs of cardiac disease, recommend cardiac ultrasound and proceed to the Cardiac Protocol if condition has been stable over a reasonable period of time and Pet will benefit immediately from the procedure to be done.
Patient < 3 years old with murmur

Patient <3: Consider congenital diseases and characterize the murmur based on timing and the point of maximal intensity [PMI]. See appropriate cardiac references or call a medical advisor for further guidance. If the patient exhibits clinical symptoms such as cough, exercise intolerance, inadequate development, cardiac cachexia, ascites, collapse or respiratory distress, consider cardiac ultrasound and refer unless its an emergency.
Mature patient with murmur

Mature patients with acquired murmurs typically develop degenerative valvular disease (primarily dogs) or myocardial disease (cats and dogs). Obtain thoracic radiographs and ECG. If the patient exhibits clinical symptoms, postpone the procedure and consider cardiac
Banfield Protocols
Dr. Green, Devin and Shelby
Banfield Protocols
PAGE 55
LABORATORY DATA
Perform a routine complete blood count and serum chemistry profile. This allows you to evaluate the Pets current health status. Laboratory data are especially important in apparently healthy patients to ensure that potential problems are uncovered. You may need to request additional diagnostics depending on the results. Address any abnormalities before anesthesia. Try to correct them before anesthesia, with the goal of preventing or minimizing adverse events and addressing any underlying conditions. An ill patients condition and laboratory values can change in just a few hours. In these situations, it is best to collect and evaluate the complete blood cell count (CBC) and serum chemistry profile just before the anesthesia procedure. Using a systematic approach to evaluate laboratory data lets you address abnormal results in a timely fashion (See Pre-anesthetic Blood Work Evaluation, page 57). Much like the physical examination algorithm, this system guides practitioners through the appropriate diagnostic tests, such as urinalysis, bile acids testing, electrocardiogram (ECG), ultrasound and supportive care, depending on the findings. By appropriately and thoroughly addressing aberrant findings before anesthesia, you place the patient in the best possible condition to undergo the procedure. Many compromised patients have electrolyte abnormalities. Depending on the underlying cause, abnormalities may or may not be clinically significant. In addition to evaluating serum electrolytes, an ECG can provide information about clinical effects of electrolyte abnormalities. For example, hyperkalemia frequently produces decreased P waves, increased PR intervals, spiked T waves and bradycardia. Address any abnormalities before anesthesia.
This approach to evaluating the pre-anesthetic patient helps you determine the best anesthesia protocol for the Pet (See Anesthesia Decision Protocol, page 50). Once you have administered premedications, it is essential to re-evaluate the Pets major organ systems using the five-step approach previously discussed, because administered drugs can have profound effects on cardiovascular and pulmonary systems before anesthesia induction. This evaluation may change your intended anesthetic protocol or prompt you to postpone anesthesia to further evaluate unexpected findings.
Conclusion
When pre-anesthetic evaluation reveals abnormalities, it is the practitioners responsibility to appropriately address each one before proceeding. How do you define appropriately address? There is no simple answer; it depends on the situation and the abnormality. Ideally, the practitioner decides if further diagnostics or supportive care is necessary. How long to administer supportive care before the anesthetic procedure (minutes, hours, days, weeks) is based on the practitioners assessment. In emergency situations, the patient may be stabilized for only a short time such as when there is only enough time to administer shock fluids to optimize perfusion. On the other hand, elective procedures may be delayed until the abnormalities are resolved or stabilized. In all cases, the practitioners goal is to place the patient in the best condition possible before the anesthetic procedure or decide anesthesia is not in the Pets best interest. In the end, the patients condition on recovery should be as good as or better than before anesthesia.
Banfield Protocols
Practice tips
It is often difficult to record an ECG on a conscious Pet, as the alligator clips can be quite painful. Rather than attaching the alligator clips directly to the patient, use a 25-gauge hypodermic needle or surgical staples in the appropriate sites. Lipemic blood samples may be seen if the patient has recently eaten or if there is an underlying condition such as hypothyroidism, diabetes mellitus, pancreatitis or primary hyperlipidemia. Additionally, lipemia can interfere with some serum chemistry profile results. If you discover lipemia, wait a few hours and draw a new blood sample for evaluation. If the second sample is also lipemic, you may want to evaluate further. If you cannot delay anesthesia, then use an anesthesia protocol without propofol, as it may be contraindicated in patients with lipemia. Additional pre-anesthetic diagnostics may include specific serum chemistries, blood pressure testing, radiography, ultrasound, microbiology, toxicology, cytology, coagulation tests or serum electrolytes. Choose the best tests to help you determine whether anesthesia is safe and in the Pets best interest.
A 25-gauge needle is used to attach the alligator clips for an ECG.
PAGE 56
Banfield Protocols
Pre-anesthetic Blood Work Evaluation
HCT, Hgb, RBC count
Platelets, clotting problems
BUN/ Creatinine
ALT/ Bilirubin/ ALP
Albumin/ total protein
If Hct<25% and/or Hgb<8 g/dl, postpone or transfuse before surgery. Give diphenhydramine at 1 mg/ lb intramuscularly (max dose 50 mg) 30 minutes before transfusion and do not use acepromazine premedication. Look for underlying cause. If Hct>40% (cat) or >45% (dog).* Look for underlying cause (dehydration, hypoxia, HCM in cats). See Pre-renal Azotemia Protocol. If other abnormalities, use appropriate protocol.
Conrm platelet abnormality/clotting problem by reviewing blood smear, checking BMBT (platelet function) and clotting cascade (ACT or PT, PTT). Platelet count<125,000/ l: Postpone all elective procedures until platelet count normalized. Von Willebrands disease or other clotting disorder: Postpone or transfuse (use fresh frozen plasma or fresh whole blood before surgery).
BUN Low: Check bile acids. Use Hepatic Protocol. High: See next step.
Check urinalysis. Urine specific gravity >1.020 (dog) and > 1.030 (cat): Rehydrate. Address underlying cause before proceeding. Consider pre-renal azotemia. Urine specific gravity < 1.020 (dog) and 1.030 (cat): Check other urinalysis parameters. Consider renal disease and proceed to Renal Protocol. Elevated BUN and creatinine: Palpate bladder. If obstructed, do urinalysis by cystocentesis and proceed to Post-Renal Protocol. BUN elevated and normal creatinine: Consider gastrointestinal bleeding.
If elevated, evaluate for liver disease. If total bilirubin <2.0 mg/dl, check bile acids and evaluate electrolytes. Consider radiographs and ultrasound. If electrolytes abnormal, treat as cardiac case. If liver disease present, proceed to Hepatic Protocol.
If total protein <3.5 g/dl, look for cause. Give plasma if possible (administer diphenhydramine at 1 mg/lb (maximum dose 50 mg) intramuscularly before infusion; wait 30 minutes. Remove acepromazine from premedication. Use Healthy Pet Protocol if no other abnormalities.
Banfield Protocols
Potassium Glucose
If high or low (suspected or documented), verify sample value. Look for cause (check renal function and urinary tract for urethral blockage or ruptured bladder). Proceed to Cardiac Protocol (perform ECG).
If<100 mg/dl, look for cause. Start 2.5% dextrose in 0.45% NaCl intravenously. Go to Healthy Pet Protocol. If >200 mg/dl, do urinalysis & serum fructosamine test and postpone anesthesia. If serum fructosamine test elevated, stabilize Pet, then use Diabetic Protocol.
WBC count
MCV, MCH, MCHC**
Calcium
If elevated, look for renal disease or neoplasia (lymphoma, perianal). Consider Addisons disease. If low, check albumin. Proceed to cardiac workup and perform ECG. If normal, proceed with anesthesia.
Lipemia
WBC <4,000/l: Review blood smear. If neutropenia with left shift, postpone surgery and make diagnosis. Otherwise, see Abdominal Protocol.
If values are abnormal, check Pet with pulse oximetry. If MCV low, check bile acids & rule out liver shunt. Postpone surgery if possible. Select Hepatic Protocol if suspect portosystemic shunt.
Recheck new blood sample in a few hours; if lipemia persists, evaluate diet, check for hypothyroidism, diabetes mellitus, pancreatitis, and primary hyperlipidemia. Proceed to Lipemia Protocol if can not postpone procedure.
*Pets living in higher altitudes and some breeds such as Greyhounds may have naturally occurring hematocrit elevations. **Normal adult versus pediatric values will vary.
Banfield Protocols
PAGE 57
Healthy Pet Protocol: Soft Tissue Surgery
Premed: Acepromazine 0.025 mg/lb plus butorphanol 0.10.2 mg/lb SC-cat/IM-dog. Wait 30 minutes. Induction: Propofol to effect 14 mg/lb IV. Maintenance: Sevourane 14% to effect in 100% O2. Support: 2.5% dextrose in 0.45% NaCl at 510 ml/lb/hr IV.
HEALTHY PET PROTOCOL: SOFT TISSUE SURGERY

Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception, and the Fractious Pet Protocol should be followed. Pre-anesthesia blood work includes a complete blood cell count (CBC) with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Maximum dose of acepromazine is 1.5 mg. Maximum dose of butorphanol is 5 mg. Additional injections of butorphanol at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control. Dilute premedications administered subcutaneously (SC) or intramuscularly (IM) to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Acepromazine should be prediluted to 1 mg/ml in a separate vial to allow proper dose administration. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An electrocardiogram (ECG) is very helpful. Heart rate is expected to decrease as sedation occurs and anxiety is controlled. Some cats with hypertrophic cardiomyopathy (HCM) will have the same or higher heart rate following premedication. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol following premedication for healthy Pets is 1 to 2 mg/lb for dogs and 2 to 3 mg/lb for cats. Because of propofols rapid induction and rapid eliminationan approximately three- to five-minute window of durationthe technique of overpressure is required to ensure a smooth transition to sevoflurane. For overpressure, sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3 L/minute for the first three
minutes (3 percent/3 L/3 min). For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min (rebreathing circuit), and sevoflurane concentration is adjusted, to effect. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate, or inadequate pain control. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has been fully recovered for at least two hours.
Banfield Protocols
Postoperative pain management

Postoperative butorphanol at 0.1 to 0.2 mg/lb IM maximum 5 mg per each dosecan be given when sevoflurane is discontinued as long as previous dose was at least one hour prior and the Pets temperature is greater than 98F. Postoperative ketoprofen at 0.9 mg/lb IM (initial dose only) can be given when sevoflurane is discontinued as long as Pet is well-hydrated, has received intra-operative fluids and no risk of significant hemorrhage exists. Continue butorphanol at 0.1 to 0.2 mg/lb IMmax 5 mg/dose q one to two hours PRN if ketoprofen alone is not controlling pain. Buprenorphine (See page 24) can be substituted for butorphanol for post-op pain management. Dysphoria is common with butorphanol, especially with multiple doses. If ketoprofen and butorphanol do not provide sufficient analgesia, replace butorphanol with oral tramadol (1 to 2 mg/lb in dogs q eight hrs and 2 mg/lb in cats q 12 hrs). Both tramadol and buprenorphine can be used with NSAIDs or corticosteroids. Do not confuse pain with dysphoria. If patient seems excitable or agitated, an additional dose of acepromazine may be necessary if it has been at least four hours since the previous dose and pulse quality and mucus membrane color are good. Give half of the premed dose of acepromazine SC-cat/IM-dog. Go home with NSAIDs and an opioid (butorphanol in syrup, buprenorphine or tramadol) as appropriate for health status and pain level (See pages 24 to 26 for doses).
PAGE 58
Banfield Protocols
Fractious Pet Protocol
Avoid Premeds. Healthy or Compromised?
Apparently healthy Pet: Telazol 12 mg/lb IM (100 mg/ml, max dose 100 mg).
Obtain blood sample. Place IV catheter. Perform exam.
Underlying health concerns: Telazol 0.51 mg/lb IM (100 mg/ml, max dose 100 mg).
If patient needs general anesthesia: Give butorphanol (0.10.2 mg/lb SC or IM) or morphine (cat: 0.05 0.15 mg/lb max dose 2.5 mg; dog: 0.20.5 mg/lb max dose 5 mg) IM as appropriate for surgery (soft tissue vs. orthopedic). Propofol induction dose is usually lowered by 50% or may not be needed in some cases.
FRACTIOUS PET PROTOCOL Think. Make a good decision.

Fractious Pet is defined as: It takes more than one PetNurse to restrain. You have to make more than one attempt to blood draw because of patient movement. Any signs of aggression. When deciding to use this protocol, make sure you are doing so prior to the Pet becoming out of control. Using the Fractious Pet Protocol after you have lost control of the Pet is not the right decision unless the injury or illness is lifethreatening. Postpone treatment for another day if possible and immobilize the patient prior to excitement. Additionally, if you have already premedicated the Pet with acepromazine prior to an excitable event, discontinue treatment and handling of the Pet and reschedule the procedure for another day. If you have given Ace, and Pet becomes fractious, STOP!
Once Telazol has taken effect, give butorphanol 0.1 to 0.2 mg/lb SC/IM or morphine (cat: 0.05 to 0.15 mg/lb max dose 2.5 mg; dog: 0.2 to 0.5 mg/lb max dose 5 mg) IM as appropriate for procedure. Maximum dose of butorphanol is 5 mg; follow up with additional 5 mg every one to two hours as needed. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake.
Banfield Protocols
Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Telazol will usually lower propofol induction dose by approximately 50 percent or may eliminate the need for it in some cases. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. Assess depth of immobilization; some patients can be intubated without further induction agents. Propofol should always be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may developespecially after rapid administration. With Telazol on board, overpressure may not be necessaryassess depth of anesthesia before utilizing this technique. (Because of propofols rapid induction and rapid eliminationabout a three- to five-minute window of durationthe technique of overpressure is required to ensure a smooth transition to sevoflurane. Sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3 L/min (3 percent/3 L/3 min.) For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation can be used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/minute (rebreathing circuit), and the sevoflurane concentration is adjusted, to effect.

The use of Telazol IM early in the course of events helps prevent catecholamine release and thus the adverse physiological events associated with catecholamines. Telazol should be volume-diluted with sterile water prior to injection to a total volume of 0.5 to 1 ml for improved absorption. Maximum dose of Telazol is 100 mg per dose; if, after 20 minutes, effects of medication are not adequate for restraint, the Telazol dose can be repeated up to a total cumulative dose of 2 mg/lb. Most Pets, depending on temperament, will be catatonic in two to three minutes. Telazol will provide eight to 30 minutes of restraint time.
Banfield Protocols
PAGE 59
If running sevoflurane 4 percent or above, look for leaks in the system, improper intubation or inadequate oxygen flow rate. If patient (usually dog) has a rough recovery, use 0.025 mg/lb acepromazine diluted IV given slowly, to effect (max dose 1.5 mg Ace) or diazepam at 0.05 to 0.1mg/lb IV slowly, to effect, (maximum dose 5 mg); if unable to access IV, then administer Ace (0.025 mg/lb) IM or diazepam (0.1 mg/lb) IM. Continuous monitoring of patients during the recovery phase is just as important as during the procedure itself. Leave the endotracheal tube in place until the Pet is able to swallow several times and/or is fighting the tube. This is especially true for brachycephalic Pets! With a feline patient, cardiomyopathy is often subclinical and not evident until the cat is challenged or the disease is very advanced. Hypertrophic myocardial changes render patients more susceptible to myocardial hypoxia and ischemia. During stress episodes such as anesthesia and surgery, there is a release of catecholamines that leads to the acceleration of the heart rate, reducing the cardiac filling time and the myocardial perfusion, thereby aggravating
diastolic dysfunction that may precipitate a left heart failure and pulmonary edema. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.

See appropriate protocol: Soft tissue surgery: See Healthy Pet Protocol, page 58. Orthopedic surgery: See Orthopedic Protocol, page 80.
Banfield Protocols
Dr. Schade and Katie
PAGE 60
Banfield Protocols
Banfield Protocols
Brittany and Max
Banfield Protocols
PAGE 61
Premed: Acepromazine 0.025 mg/lb plus butorphanol 0.1-0.2 mg/lb SC or IM.
Feline Declaw Protocol
Wait 30 minutes. Induction: Propofol to effect 14 mg/lb IV. Local Block: See Figure 2, page 63. Maintenance: Sevourane 14% to effect, inhaled. Support: 2.5% dextrose/0.45% NaCl at 5-10 ml/lb/hr IV.
Post Surgical Pain Management: Day 1: Butorphanol 0.10.2 mg/lb q 12 hrs as needed; ketoprofen 0.9 mg/lb once. Day 2: Ketoprofen 0.45 mg/lb, and butorphanol and/or Ketofen syrup as appropriate for health status/pain level.
FELINE DECLAW PROTOCOL

Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception and the Fractious Pet Protocol should be followed. Pre-anesthetic blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Acepromazine should be prediluted to 1 mg/ml in a separate vial to allow proper dose administration. Allow 30 minutes for premeds to take effect before induction of general anesthesia. An ECG may be beneficial during cardiac assessment. Assess cardiovascular parameters after premeds have taken effect and before induction. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol following premeds for healthy Pets is 1 to 2 mg/lb for dogs and 2 to 3 mg/lb for cats. Because of propofols rapid induction and rapid eliminationan approximately three- to five-minute window of durationthe technique of overpressure is required to assure a smooth transition to sevoflurane. For overpressure, sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3L/minute for the first three minutes (3 percent/3 L/3 min). For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min (rebreathing circuit), and sevoflurane concentration is adjusted, to effect. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate.
Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours. Apply the tourniquet distal to the elbow. Improper placement may cause neuropraxia, tissue necrosis and lameness. The radial nerve is most often affected, so it is important to place the tourniquet distal to the elbow. Perform a regional carpal block using 2 percent lidocaine. This technique is easy to perform and provides exceptional short-term analgesia postoperatively. Lidocaine was chosen over bupivacaine or a mixture of the two due to lidocaine's rapid onset of action (two to five minutes) and how this fits into our surgical plan for declaws (most individuals will not wait the 10-plus minutes for bupivacaine or a mixture of lidocaine or bupivacaine to start working before they cut). Calculate lidocaine dose carefully to avoid toxicity due to overdose. Maximum lidocaine dose for a local block is 2 mg/ lb total per cat. Example: 5 lb cat x 2 mg/lb = 10 mg. Lidocaine is a 2 percent solution (20 mg/ml). 10 mg/ 20 mg/ml = 0.5 ml max to be injected into cat. If additional volume is needed, lidocaine can be volume diluted with sterile saline. Superficial branches of the radial nerve are blocked by injecting the local anesthetic solution subcutaneously on the dorsomedial aspect of the carpus just proximal to the joint (See Figure 2, page 63) . The median nerve and the palmar and dorsal cutaneous branches of the ulnar nerve are blocked by injecting local anesthetic solution subcutaneously medial and lateral to the carpal pad (See Figure 2, page 63). Use a 25- to 22-gauge needle for subcutaneous injection. Avoid intravascular injection. Lidocaine requires two to five minutes to achieve effect and its duration of action is one to two hours.
Banfield Protocols
PAGE 62
Banfield Protocols
A second option is to perform a ring block just proximal to the carpus. This may require a larger volume of lidocaine, thus volume dilution may be needed. Do not exceed the maximum safe dose of lidocaine.
Dysphoria is common with butorphanol, especially with multiple doses. If ketoprofen and butorphanol do not provide sufficient analgesia, can replace the butorphanol with oral tramadol (2 mg/lb in cats q 12 hrs). Both tramadol and buprenorphine can be used with NSAIDs or corticosteroids. Do not confuse pain with dysphoria. If patient seems excitable or agitated, an additional dose of acepromazine may be necessary if it has been at least four hours since the previous dose and pulse quality and mucus membrane color are good. Give half of the premed dose of acepromazine SC. The following morning, administer a second dose of ketoprofen (0.45 mg/lb IM SID) before removing bandages. Maximum of three doses of ketoprofen. Administer a second dose of butorphanol one to two hours following first dose, as butorphanols duration of action is only one to two hours. It's OK to switch to buprenorphine. Butorphanol may be repeated every two hours if the cat seems to be in pain; it should be given before bandage removal. Go home with NSAIDs and an opioid (butorphanol in syrup, or buprenorphine or tramadol) as appropriate for health status and pain level. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours. Figure 2: Regional Carpal Block
Effectiveness of butorphanol for analgesia after feline onychectomy

Pain management has become a cornerstone in the practice of quality veterinary medicine. Numerous opinions exist regarding the appropriateness of various modes of pain control for feline onychectomy (declaw). Some sources report transdermal fentanyl as a favored post-declaw pain management choice, giving many practitioners the impression that other opioids, such as butorphanol, are inappropriate or ineffective. However, independent research has found this impression to be false. In prospective and randomized prospective studies, butorphanol was found to generally be as effective as transdermal fentanyl in controlling post-operative feline onychectomy pain. 1, 2 Pressureplatform gait analysis, serum cortisol levels and subjective pain scale behavior observation were used to evaluate the analgesic effects of butorphanol and transdermal fentanyl. The analgesic effectiveness of butorphanol, given intramuscularly (IM) at appropriate intervals postoperatively, was found to be very similar to transdermal fentanyl. As well as butorphanol, current Banfield standards for feline onychectomy include pre-emptive analgesia with local anesthetic blocks and postsurgical analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs) and/or additional opioid administration (butorphanol or buprenorphine). This effective combination of pain management modalities ensures a high level of post-declaw pain control for feline patients.
References 1. Romans CW, Gordon WJ, Robinson DA, Evan RB, Conzemius MG. Effect of postoperative analgesic protocol on limb function following onychectomy in cats. JAVMA. Jul 2005;227(1). 2. Gellasch KL, Elliott KT, Osmond CS, Shih AN, Bjorling DE. Comparison of transdermal administration of fentanyl versus intramuscular administration of butorphanol for analgesia after onychectomy in cats. JAVMA. Apr 2002;220(7).
Banfield Protocols
Median n.

Postoperative butorphanol at 0.1 to 0.2 mg/lb IM maximum 5 mg per each dosecan be given when sevoflurane is discontinued as long as previous dose was at least one hour prior and the Pets temperature is greater than 98F. Upon completion of surgery, administer ketoprofen (0.9 mg/lb IM once) if renal and liver function are within normal limits. Ketoprofen requires approx. 45 minutes for effect. Continue butorphanol at 0.1 to 0.2 mg/lb IMmax 5 mg/dose q one to two hours PRN if ketoprofen alone is not controlling pain. Buprenorphine (See page 24) can be substituted for butorphanol for post-op pain management.
Infusion area Infusion area
Dorsal br. Palmar br. Radial n. Ulnar n.
From left, dorsal and palmar views of the front feline paw.
Banfield Protocols
PAGE 63
Lipemia Protocol
Re-check new blood sample in a few hours. If lipemia persists, evaluate diet, check for hypothyroidism, diabetes mellitus, pancreatitis, and primary hyperlipidemia.
If anesthesia is still required, use appropriate protocol for premeds, maintenance and support. For induction, use Telazol as follows: Telazol 0.51 mg/lb IV slowly to effect. (Telazol should be diluted with sterile water to a volume of 13 ml and given to effect to allow for intubation.)
LIPEMIA PROTOCOL
Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception, and the Fractious Pet Protocol should be followed. Pre-anesthetic blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Maximum dose of acepromazine is 1.5 mg. Maximum dose of butorphanol is 5 mg. Additional amounts of butorphanol at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Acepromazine should be prediluted to 1 mg/ml in a separate vial to allow proper dose administration. Allow 30 minutes for premeds to take effect before induction of general anesthesia. ECG is very helpful. Assess cardiovascular parameters after premeds have taken effect and before induction. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. The induction dose of Telazol for healthy lipemic patients is 0.5 to 1 mg/lb. The calculated dose should be drawn in a syringe and then volume-diluted with sterile saline to a volume of 1 to 3 ml. Telazol should be titrated, to effect. Anesthetic induction with Telazol is used only in healthy patients with lipemia. When using a dissociative for induction (Telazol or other dissociatives), do not use the overpressure technique. Begin with oxygen flow rates of 1 to 1.5 L/minute (rebreathing circuit) and a sevoflurane concentration of 1 to 1.5 percent. Overpressure may result in excessive anesthetic depth during the initial phase of general anesthesia. This is made worse by rapid respiratory rates. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate.
Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours. If patient (usually dog) has a rough recovery, use 0.025 mg/lb acepromazine diluted IV given slowly, to effect (max dose 1.5 mg Ace) or diazepam at 0.05 to 0.1mg/lb IV slowly to effect (maximum dose 5 mg); if unable to access IV, then administer Ace (0.025 mg/lb) IM or diazepam (0.1 mg/lb) IM.
Banfield Protocols

See appropriate protocol: Soft tissue surgery: See Healthy Pet Protocol, page 58. Orthopedic surgery: See Orthopedic Protocol, page 80.
PAGE 64
Banfield Protocols
Banfield Protocols
Leanna and Tinkerbell
Banfield Protocols
PAGE 65
Stabilize Before Surgery

Premed: Diazapam 0.1 mg/lb (10 mg max) IM* plus butorphanol 0.10.2 mg/lb (5 mg max) SC-cat/IM-dog Do not use acepromazine Wait 30 minutes Induction: Propofol to effect 14 mg/lb IV Maintenance: Sevourane 14% to effect, inhaled Support: 0.9% NaCl 5-10 ml/lb/hr IV. Do not use uid containing dextrose.
Abdominal Protocol Check pulse ox & ECG
Pyometra C-section Cystitis/uroliths Peritonitis Intussusceptions GDV
If HCT below 25% and/or TP below 3.5, give appropriate transfusion* (whole blood, packed RBCs, plasma, Oxyglobin).
ABDOMINAL PROTOCOL
* If a transfusion is given, then diphenhydramine 1 mg/lb IM (max dose 50 mg) should be substituted for diazepam in the premeds. Stabilize prior to anesthesia: Manage shock. Manage arrhythmias. Provide pain management (butorphanol 0.1 to 0.2 mg/lb q 1 to 4 hr as needed). If the patient is shocky, anesthesia is contraindicated. Correct shock before induction. In the event of an emergency when correcting shock is not possible, mask induction with sevoflurane may be used. If possible, consult with a medical advisor or director before proceeding with mask induction. Avoid stress when utilizing mask induction; if heart rate increases by 25 percent or more during mask induction, allow patient to relax, then administer appropriate IV induction agent. Gastric dilatation volvulus (GDV) cases require stabilization and decompression before general anesthesia. They dont meet the definition of emergency. Emergencies are surgical cases that require anesthesia within 15 minutes to save the patients life. Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception and the Fractious Pet Protocol should be followed. Pre-anesthetic blood work includes a CBC with differential and internal organ function screen. Perform and review immediately before administering premeds. Maximum dose of butorphanol is 5 mg. Additional amounts at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control. Do not use acepromazine. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake.
Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol is often less than is required by healthy Pets. Err on the side of caution. Sevoflurane concentration necessary to keep these patients in a general plane of anesthesia is usually significantly lower than is required by healthy Pets. Because of propofols rapid induction and rapid eliminationan approximately three- to five-minute window of durationthe technique of overpressure is required to assure a smooth transition to sevoflurane. For overpressure, sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3 L/minute for the first three minutes (3 percent/3 L/3 min). For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min (rebreathing circuit), and sevoflurane concentration is adjusted, to effect. This may not be necessary in severely compromised Pets. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery.
Banfield Protocols
PAGE 66
Banfield Protocols
ABDOMINAL PROTOCOL (cont'd)

Use saline without dextrose as the IV fluid of choice in critical cases (cardiac/pulmonary/abdominal). If cardiac arrest occurs, any drug can be administered through the existing IV with decreased concern regarding interaction of cardiac drugs with fluid components. Critically ill patients may be slow to recover from anesthesia. Monitor and document temperature, pulse, respiration and other vitals frequently and provide supportive care as necessary. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.
substituted for butorphanol for post-op pain management. Dysphoria is common with butorphanol, especially with multiple doses. Postoperative ketoprofen at 0.9 mg/lb IM (single dose only) can be given when sevoflurane is discontinued as long as Pet has no underlying renal or liver problems, is wellhydrated, has received intra-operative fluids and no risk of significant hemorrhage exists. If butorphanol does not provide sufficient analgesia, can replace the butorphanol with oral tramadol (1 to 2 mg/lb in dogs q 8 hrs and 2 mg/lb in cats q 12 hrs). Both tramadol and buprenorphine can be used with NSAIDs or corticosteroids. Do not confuse pain with dysphoria. If patient seems excitable or agitated, an additional dose of diazepam may be indicated; dose at 0.05 to 0.1 mg/lb IV slowly to effect (maximum dose 5 mg). Go home on NSAID and opioid (butorphanol in syrup, buprenorphine or tramadol) as appropriate for health status and pain level. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.

Postoperative butorphanol at 0.1 to 0.2 mg/lb IM (max 5 mg per each dose) can be given when sevoflurane is discontinued as long as previous dose was at least one hour prior and the Pets temperature is greater than 98F. Continue butorphanol at 0.1 to 0.2 mg/lb IMmax 5 mg/dose q one to two hours PRN if ketoprofen alone is not controlling pain. Buprenorphine (See page 24) can be
Banfield Protocols
Christine and Toby
Banfield Protocols
PAGE 67
Cardiac Protocol
If ECG normal, pulse quality good and no clinical signs of cardiac disease are present, proceed to Healthy Pet Protocol.
If still bradycardic,* stop and review diagnosis. Perform cardiac workup.
ECG
Sinus Bradycardia
Premed: Glycopyrrolate 0.005 mg/lb IM (max dose 0.4 mg).
If bradycardia resolves, bradycardia is vagally mediated.
If ECG abnormalities other than VPC or heart block, consider signicance. Perform further cardiac evaluation or proceed if anesthesia necessary.
Premedications: Diazepam 0.1 mg/lb (10 mg max) IM plus butorphanol 0.1-0.2 mg/lb (5 mg max) SC-cat/IM-dog. Wait 30 minutes. Induction: Propofol to effect 14 mg/lb IV
Banfield Protocols
If ECG normal, but there are clinical signs of cardiac disease, consider further evaluation (chest radiographs, cardiac ultrasound) or proceed if anesthesia necessary.
Maintenance: Sevourane 14% to effect, inhaled. Support: 0.9% NaCl at 510 ml/lb/hr IV.
If ventricular premature contractions (VPCs), avoid glycopyrrolate and atropine even if bradycardia exists. Recommend further evaluation before proceeding or proceed if anesthesia necessary.
Premedications: Diazepam 0.1 mg/lb (10 mg max) IM plus butorphanol 0.1-0.2 mg/lb (5 mg max) SC-cat/IM-dog. Wait 30 minutes, if possible.
VPCs gone pre-oxygenate 3-5 minutes avoid stress.**
Lidocaine Dog: 12 mg/lb IV Cat: 0.1250.25 mg/ lb IV. Given slowly to effect. If VPCs still present, postpone anesthesia if possible. Otherwise, start lidocaine.
Dog: Lidocaine drip (50 ml of 2% lidocaine to 1 liter saline) give dog 510 ml/lb/hr until VPC gone then slow to 2 ml/hr and monitor the bradycardia. If bradycardia develops, slow/stop drip and monitor for VPCs. Lidocaine drip requires a second IV catheter and line. Cat: Lidocaine drip (50 ml of 2% Lidocaine to 1 liter saline) give cat 0.30.5 ml/lb/hr until VPC gone. If bradycardia develops, slow/ stop drip and monitor for VPCs. Lidocaine drip requires a second IV catheter and line.
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Banfield Protocols
CARDIAC PROTOCOL
* Patients that are bradycardic after glycopyrrolate or atropine may still have a vagal stimulus present. Check for increases in ocular or intracranial pressure or full bladder. ** Avoid stress means the heart rate does not increase by 25 percent or more. Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception and the Fractious Pet Protocol should be followed. (Telazol should be used only with caution in cardiac patients.) Telazol should be avoided in patients with cardiac disease whenever possible. Following administration of Telazol, there is an increase in the sympathetic tone, leading to elevations in heart rate, myocardial contractility and blood pressure. Due to these effects, there is increased myocardial work and oxygen consumption, which is potentially dangerous in patients with cardiac diseases. Pre-anesthesia blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Maximum dose of butorphanol is 5 mg. Additional amounts of butorphanol at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. If premeds are given more than three hrs before induction, repeat premeds at half dose 30 minutes before induction. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol in healthy Pets following premeds is 1 to 2 mg/lb for dogs and 2 to 3 mg/lb for cats. Because of propofols rapid induction and rapid eliminationan approximately three- to five-minute window of durationthe technique of overpressure is required to assure a smooth transition to sevoflurane. For overpressure, sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3 L/minute for the first three minutes (3 percent/3 L/3 min). For this technique to be ef-
fective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min (rebreathing circuit), and sevoflurane concentration is adjusted, to effect. This may not be necessary in severely compromised Pets. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. Use saline without dextrose as the IV fluid choice in critical cases (cardiac/pulmonary/abdominal). If cardiac arrest occurs, any drug can be administered through the existing IV with decreased concern regarding interaction of cardiac drugs with fluid components. Critically ill patients may be slow to recover from anesthesia. Monitor and document TPR and other vitals frequently and provide supportive care as necessary.
Banfield Protocols
It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.

Postoperative butorphanol at 0.1 to 0.2 mg/lb IM (max 5 mg per each dose) can be given when sevoflurane is discontinued as long as previous dose was at least one hour prior and the Pets temperature is greater than 98F. Continue butorphanol at 0.1 to 0.2 mg/lb IMmax 5 mg/dose q one to two hours PRN if ketoprofen alone is not controlling pain. Buprenorphine (See page 24) can be substituted for butorphanol for post-op pain management. Postoperative ketoprofen at 0.9 mg/lb IM (single dose only) can be given when sevoflurane is discontinued as long as Pet has no underlying renal or liver problems, is well-hydrated, has received intra-operative fluids and no risk of significant hemorrhage exists. Butorphanol does not provide sufficient analgesia, can replace the butorphanol oral tramadol (1 to 2 mg/lb in dogs q 8 hrs and 2 mg/lb in cats q 12 hrs). Both tramadol and buprenorphine can be used with NSAIDs or corticosteroids. Do not confuse pain with dysphoria. If patient seems excitable or agitated, an additional dose of diazepam may be indicated; dose at 0.05 to 0.1 mg/lb IV slowly to effect (maximum dose 5 mg). Go home on NSAID and opioid (butorphanol in syrup, buprenorphine or tramadol) as appropriate for health status and pain level.
Banfield Protocols
PAGE 69
Hepatic Protocol
Do ACT (activated clotting time) or clotting prole (PT, PTT, platelet count) prior to any procedure whenever possible.
Premed: Butorphanol 0.10.2 mg/lb (5 mg max) SCcat/IMdog plus 0.1 mg/lb diazepam* IM (max dose 10 mg). Do not use acepromazine. Wait 30-40 minutes. Induction: Propofol to effect 14 mg/lb IV. Maintenance: Sevourane 14% to effect, inhaled. Support: 2.5% dextrose in 0.45% NaCl at 510 ml/lb/hr IV.
If clotting tests are abnormal, postpone or transfuse* (FFP, fresh whole blood).
During recovery, continue 2.5% dextrose in 0.45% NaCl at 5 ml/lb/ hr. If recovery greater than 20 minutes, warm patient & check blood glucose.
HEPATIC PROTOCOL
*If a transfusion is given, substitute diphenhydramine [1 mg/lb IM (maximum single dose 50 mg)] for diazepam in the premeds. A coagulopathy secondary to liver failure indicates severe hepatobiliary disease and is associated with a poor prognosis. Recommend vitamin K injection and recommend having the fresh frozen plasma (FFP) or blood available even if coagulating parameters are normal.
If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol is often less than is required by healthy Pets. Err on the side of caution. Because of propofols rapid induction and rapid eliminationan approximately three- to five-minute window of durationthe technique of over pressure is required to assure a smooth transition to sevoflurane. For overpressure, sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3 L/minute for the first three minutes (3 percent/3 L/3 min). For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min (rebreathing circuit), and sevoflurane concentration is adjusted, to effect. This may not be necessary in severely compromised Pets. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. Critically ill patients may be slow to recover from anesthesia. Monitor and document TPR and other vitals, including blood glucose, frequently and provide supportive care as necessary. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.
Banfield Protocols
Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception and the Fractious Pet Protocol should be followed. Pre-anesthesia blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Activated clotting time (ACT or PT, PTT) should be performed just before induction to assess coagulation the day of surgery. Clinical and subclinical coagulopathies can occur with severe hepatobiliary disease since most clotting factors are synthesized in the liver. Some patients with normal coagulation tests can still have bleeding tendencies due to changes in coagulation factor activity, disseminated intravascular coagulation (DIC) and portal hypertension induced vascular congestion and fragility. Buccal mucosal bleeding time (BMBT) is not a valuable test for patients with liver disease as it only indicates functionality of platelets, not clotting factors. Maximum dose of butorphanol is 5 mg. Additional amounts at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control. Do not use acepromazine. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment.
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Banfield Protocols

Postoperative butorphanol at 0.1 to 0.2 mg/lb IMmaximum 5 mg per each dosecan be given when sevoflurane is discontinued as long as previous dose was at least one hour prior and the Pets temperature is greater than 98F. Continue butorphanol at 0.1 to 0.2 mg/lb IMmax 5 mg/dose q one to two hours PRN if ketoprofen alone is not controlling pain. Buprenorphine (See page 24) can be substituted for butorphanol for post-op pain management. Dysphoria is common with butorphanol, especially with multiple doses. If butorphanol does not provide sufficient analgesia, can replace the butorphanol with oral tramadol (1 to 2 mg/lb in dogs q 8 hrs and 2 mg/lb in cats q 12 hrs). Both tramadol and buprenorphine can be used with NSAIDs or corticosteroids.
Do not confuse pain with dysphoria. If patient seems excitable or agitated, an additional dose of diazepam may be indicated; dose at 0.05 to 0.1 mg/lb IV slowly to effect (maximum dose 5 mg). Go home with an opioid (butorphanol in syrup, buprenorphine or tramadol) as appropriate for health status and pain level. If performed orthopedic surgery, see Orthopedic Protocol for post-op pain medication recommendations.
Banfield Protocols
Jessie and Kitten
Banfield Protocols
PAGE 71
Stable Diabetic Protocol
Check ECG If abnormalities, use Cardiac Protocol
Instead of regular meal and insulin dose, feed 1/2 meal and administer 1/2 dose insulin 2 hours prior to anesthesia. This should be performed as close as possible to the Pets regular feeding and insulin administration time. Check glucose (N 110175) just before anesthesia. If possible, set up anesthesia time based on normal feeding schedule.
Premed: Acepromazine 0.025 mg/ lb plus butorphanol 0.10.2 mg/ lb SCcat/IM-dog, or Orthopedic Protocol premeds if appropriate for procedure. Induction: Propofol to effect 14 mg/lb IV. Maintenance: Sevourane 14% to effect, inhaled. Support: 0.9% NaCl 510 at ml/lb/ hr IV.* Check blood glucose q 30 minutes* while under general anesthesia.
Post-op care: Check glucose every 24 hrs until Pet is awake and stable.
STABLE DIABETIC PROTOCOL

Banfield Protocols
* Check blood glucose every 30 minutes while under general anesthesia. If hypoglycemia develops (BG < 100 g/dl), take appropriate steps to correct, i.e., start 2.5 percent dextrose/0.45 percent NaCl IV. Saline is used as the IV fluid choice in diabetic Pets to avoid glucose increase. Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception and the Fractious Pet Protocol should be followed. Pre-anesthesia blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Maximum dose of acepromazine is 1.5 mg. Maximum dose of butorphanol is 5 mg. Additional amounts at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Acepromazine should be prediluted to 1 mg/ml in a separate vial to allow proper dose administration. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction.
Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol in healthy Pets following premedication is 1 to 2 mg/lb for dogs and 2 to 3 mg/lb for cats. Because of propofols rapid induction and rapid eliminationan approximately three- to five-minute window of durationthe technique of overpressure is required to assure a smooth transition to sevoflurane. For overpressure, sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3 L/minute for the first three minutes (3 percent/3 L/3 min). For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min, and sevoflurane concentration is adjusted, to effect. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.
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Banfield Protocols
NON-STABLE DIABETIC PROTOCOL

Non-stable diabetics should not be anesthetized unless there is a critical emergency that warrants the risk. If a true emergency procedure must be done, the following procedures are recommended: Correction of hypovolemia secondary to dehydration. Thorough evaluation and correction of any electrolyte abnormalities. Continuous evaluation of the blood glucose levels (minimally every hour) and the addition or deletion of dextrose from the patient's intravenous (IV) fluids. Stabilization of hyperglycemia through the use of regular insulin injections (Humulin R, for example) or constant rate infusion (CRI).
Stabilization of hypoglycemia through the use of IV dextrose boluses (1 ml 50 percent dextrose per kg of body weight) or CRI. The goal of anesthetizing a diabetic patient is to achieve full consciousness and recovery as quickly as possible so the patient can return to a normal feeding schedule and metabolic state (Thurman WJ, Grimm KA. Lumb & Jones' Veterinary Anesthesia and Analgesia. 4th ed. Oxford, England: Blackwell Publishing; 2007; 933). Ideal blood glucose levels will be between 150 and 250 mg/dL (Thurman WJ, Grimm KA. Lumb & Jones' Veterinary Anesthesia and Analgesia. 4th ed. Oxford, England: Blackwell Publishing; 2007; 933).

See protocol most appropriate for health status of Pet and procedure done: Hepatic, Renal, Cardiac, Healthy Pet, Orthopedic.
Banfield Protocols
Dr. Wood and Eugenia
Banfield Protocols
PAGE 73
Pulmonary Protocol Check pulse ox now
Pulse ox normal and air movement present: If obese with no other abnormalities, proceed. If pneumonia or asthma present, consider radiographs.
Pneumothorax or pleural effusion present: Drain chest & stabilize. Local block/immobilization preferred for chest tube placement.
ECG If ECG normal, proceed. If ECG abnormal, see Cardiac Protocol. Resolve ECG abnormalities, then use Pulmonary Protocol for induction and maintenance.
Acepromazine 0.025 mg/lb plus butorphanol 0.1 mg/ lb SC-cat/IM-dog. Pre-oxygenate 35 minutes.
Pulse ox abnormal or respiratory distress present: Consider radiographs & thoracocentesis (look for pneumothorax, pleural effusion or diaphragmatic hernia). If sedation needed for diagnosis, use acepromazine 0.025 mg/lb (max dose 1.5 mg) plus butorphanol 0.1 mg/lb (max dose 5 mg) SC/IM. Note: If high risk, avoid acepromazineuse diazepam 0.1 mg/ lb IM instead (max dose 10 mg). Avoid stress* and provide O2.
Premed: See earlier box if not already sedated. Diaphragmatic Hernia Induction: Propofol to effect 14 mg/lb IV. Use rapid sequence induction** & be prepared to ventilate. Maintenance: Sevourane 1-4% to effect, inhaled. Support: 0.9% NaCl at 510 ml/lb/hr IV. Manual ventilation may be required.
PULMONARY PROTOCOL
Banfield Protocols
* Avoid stress means: the heart rate does not increase by 25 percent or more. ** Rapid sequence induction = have all needed supplies available at induction for quick intubation. Any delay in providing oxygen and an open airway increases risk of death. If upper airway is blocked, provide oxygen through an 18-gauge catheter needle placed into the trachea between the trachea rings as short-term emergency support. When ventilating patients with chronic pulmonary disease, be sure to watch the manometer. Pressures should not exceed 12 to 15 cm H20. Higher pressures can cause micro hemorrhage in the alveoli of compromised lung tissue. Such patients may wake up from anesthesia, only to die within a few hours of recovery. Perform a complete physical examination and preanesthetic blood work before any pre-anesthetic or anesthetic drug administration. Fractious patients are the exception and the Fractious Pet Protocol should be followed. Pre-anesthetic blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Maximum dose of acepromazine is 1.5 mg. Acepromazine should be prediluted to 1 mg/ml in a separate vial to allow proper dose administration. Maximum dose of butorphanol is 5 mg. Additional amounts of butorphanol at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control.
Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol in healthy Pets following premedication is 1 to 2 mg/lb for dogs and 2 to 3 mg/lb for cats. Sick Pets usually require less. Because of propofols rapid induction and rapid eliminationan approximately 3- to 5-minute window of durationthe technique of overpressure is required to assure a smooth transition to sevoflurane. For overpressure, sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3 L/minute for the first three minutes (3 percent/3 L/3 min). For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min (rebreathing circuit), and sevoflurane concentration is adjusted, to effect. This may not be necessary in severely compromised Pets. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate.
PAGE 74
Banfield Protocols
Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. Use saline without dextrose in critical cases (cardiac/ pulmonary/abdominal). If cardiac arrest occurs, any drug can be administered through the existing IV with decreased concern regarding interaction of cardiac drugs with fluid components. Critically ill patients may be slow to recover from anesthesia. Monitor and document TPR and other vitals frequently and provide supportive care as necessary. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.

Bradyarrythmias are common in patients with respiratory disease due to increased vagal tone, e.g., brachycephalic breeds, patients with intrathoracic disease (syndrome). Patients symptomatic for bradyarrythmias may display weakness, lethargy, depression and syncope. Sinus bradycardia is most often seen with increased vagal tone. Treatment is based on management of the underlying cause. A vagalytic/parasympathetic agent (atropine, 0.002 to 0.004 mg/lb) may be used in the awake, unmedicated patient to see if increased vagal tone is the source of the bradycardia. This dose is less likely to cause rebound sinus tachycardia and is much lower than the dose used to treat bradycardia that develops under anesthesia.

See appropriate protocol and consider premeds that are on board. Soft tissue surgery: See Healthy Pet Protocol. Orthopedic surgery: See Orthopedic Protocol. Ill Pet: See Renal, Hepatic or Abdominal Protocols.
Banfield Protocols
Jazmin, Kate and Josie
Banfield Protocols
PAGE 75
Obesity Protocol Check pulse ox now
Normal oxygen saturation and normal respiration.
Acepromazine 0.025 mg/lb plus Butorphanol 0.1 mg/lb SC-cat/IM-dog. Pre-oxygenate 35 minutes.
Abnormal oxygen saturation OR abnormal respiration.
Premed: See earlier box. Induction: Propofol to effect 14 mg/lb IV. Maintenance: Sevourane 1-4% to effect, inhaled. Support: NaCl at 510 ml/lb/hr IV. Monitor oxygen saturation carefully. Intermittent manual ventilation may be needed in significantly obese patients.
Go to pulmonary protocol if non-elective procedure.
OBESITY PROTOCOL
Perform a complete physical examination and preanesthetic blood work before any pre-anesthetic or anesthetic drug administration. Fractious patients are the exception and the Fractious Pet Protocol should be followed.
Banfield Protocols
Pre-anesthetic blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Maximum dose of acepromazine is 1.5 mg. Acepromazine should be prediluted to 1 mg/ml in a separate vial to allow proper dose administration. Maximum dose of butorphanol is 5 mg. Additional amounts of butorphanol at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control. Dilute premedications administered SC or IM to a total volume of 0.5 to 3.0 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol in healthy Pets following premedication is 1 to 2 mg/lb for dogs and 2 to 3 mg/lb for cats. Sick Pets usually require less. Because of propofols rapid induction and rapid eliminationan approximately three- to five-minute window of durationthe technique of overpressure is required to
assure a smooth transition to sevoflurane. For overpressure, sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3 L/minute for the first three minutes (3 percent/3 L/3 min). For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min (rebreathing circuit), and sevoflurane concentration is adjusted, to effect. This may not be necessary in severely compromised Pets. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. Use saline without dextrose as the IV fluid choice in critical cases (cardiac/pulmonary/abdominal). If cardiac arrest occurs, any drug can be administered through the existing IV with decreased concern regarding interaction of cardiac drugs with fluid components. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.

See appropriate protocol and consider premeds that are on board. Soft tissue surgery: See Healthy Pet Protocol. Orthopedic surgery: See Orthopedic Protocol. Ill Pet: See Renal, Hepatic or Abdominal Protocols.
PAGE 76
Banfield Protocols
Banfield Protocols
Dr. Wegert
Banfield Protocols
PAGE 77
Renal Protocol
Pre-Renal Azotemia: Elevated HCT, BUN & Creat w/urine specic gravity > 1.020 dog/1.030 cat.
Correct dehydration with uid therapy at 5 ml/lb/hr for 1-2 hours prior to anesthesia.
Recheck HCT & TP If normal, proceed with Healthy Pet Protocol. Premed: Diazepam 0.1 mg/lb IM (max dose 10 mg) plus butorphanol 0.10.2 mg/lb (max dose 5mg) SC-cat/IM-dog. No acepromazine. Wait 30 minutes. Induction: Propofol to effect 14 mg/lb IV. Maintenance: Sevourane 14% to effect, inhaled. Support: 2.5% dextrose/0.45% NaCl at 510 ml/lb/hr IV.
Renal Azotemia: Evaluate for severity and underlying cause.
Provide uid therapy at 1-5 ml/lb/hr for 1-2 hours prior to anesthesia. If stable and wellhydrated, proceed with anesthesia as necessary.
Post Renal Azotemia: (Blocked Urethra).* *See page 79 for Post-Renal Protocol
Banfield Protocols
RENAL PROTOCOL
Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Pre-anesthesia blood work includes a CBC with differential and internal organ function screen. Perform these tests immediately before administration of premeds or induction agent if possible. Maximum dose of butorphanol is 5 mg. Additional amounts of butorphanol at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. Assess depth of immobilization; some patients can be intubated without further induction agents. These Pets generally require much lower doses of both induction agents and general anesthetics than healthy Pets. Err on the side of caution. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. Sevoflurane concentration necessary to keep these patients in a general plane of anesthesia is usually significantly lower than for a healthy Pet.
If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. Critically ill patients may be slow to recover from anesthesia. Monitor and document TPR and other vitals frequently and provide supportive care as necessary. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.

Postoperative butorphanol at 0.1 to 0.2 mg/lb IM maximum 5 mg per each dosecan be given when sevoflurane is discontinued as long as previous dose was at least one hour prior and the Pets temperature is greater than 98F. Continue butorphanol at 0.1 to 0.2 mg/lb IMmax 5 mg/dose q one to two hours PRN if ketoprofen alone is not controlling pain. Buprenorphine (See page 24) can be substituted for butorphanol for post-op pain management. Dysphoria is common with butorphanol, especially with multiple doses. If butorphanol does not provide sufficient analgesia, can replace the butorphanol with oral tramadol (1 to 2 mg/lb in dogs q 8 hrs and 2 mg/lb in cats q 12 hrs). Both tramadol and buprenorphine can be used with NSAIDs or corticosteroids. Do not confuse pain with dysphoria. If patient seems excited or agitated, an additional dose of diazepam may be indicated; dose at 0.05 to 0.1 mg/lb IV slowly, to effect (maximum dose 5 mg).
PAGE 78
Banfield Protocols
Post-Renal Protocol
Post-Renal Azotemia: (Blocked urethra)
Stabilize Pet: Check ECG Start Normosol-R or saline 0.9% at 510 ml/lb/hr IV and empty bladder via cystocentesis. Perform electrolyte assay.
If Pet too fractious to allow placement of IV catheter, ECG, blood draw, cystocentesis or urethral catheterization, give the following: Premed: Diazepam 0.1 mg/lb IM (max dose 10mg) plus butorphanol 0.10.2 mg/lb (max dose 5mg) SCcat/IM-dog.
Wait 30 minutes, then place IV catheter, empty bladder, collect blood sample, check ECG. Recheck any electrolyte abnormalities if needed.
If unable to get blood sample, empty bladder or place IV catheter, give Telazol 0.5 mg/lb (max dose 100 mg) IM.
Attempt to relieve urethral obstruction. (Cats: Place 0.1 ml of 2% lidocaine in urethra).
If general anesthesia needed, stabilize Pet rst. Induction: Propofol to effect 1-4 mg/lb IV. Maintenance: Sevourane 1-4% to effect, inhaled. Support: 2.5% dextrose in 0.45% NaCl at 5-10 ml/lb/hr IV.
POST-RENAL PROTOCOL
(See Renal Protocol, page 78, for additional details.) Bladder rupture by cystocentesis is rare, while anesthesia death in patients with urethral obstruction is common. Primary goal is to lower the potassium level. The most common ECG abnormalities are because of hyperkalemia (ECG abnormalities: bradycardia, 1st degree AV block, dropped P waves, spiked T waves) and need to be corrected before heavy sedation or general anesthesia.
If the patient is shocky, anesthesia is contraindicated. Correct shock before induction. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia may develop after rapid administration.
Banfield Protocols
Banfield Protocols
PAGE 79
Orthopedic Protocol
Premed: Acepromazine 0.025 mg/lb SC/IM (max dose 1.5 mg) plus morphine: cat0.050.15 mg/lb (max dose 2.5mg) dog0.2-0.5 mg/lb (max dose 5mg) IM only.* Wait 30 minutes. Induction: Propofol to effect 14 mg/lb IV. Maintenance: Sevourane 14% to effect, inhaled +/- epidural** or apply fentanyl patch.*** Support: 2.5% dextrose in 0.45% NaCl at 510 ml/lb/hr IV.
Postsurgical pain management: Morphine can be given at premed dose q 46 hrs if cardiovascular function is normal. Transition to: Cats: Ketoprofen 23 days. Dogs: Etogesic or Rimadyl 57 days.
Fentanyl patch dose: 1122 lbs: 25g patch 2244 lbs: 50g patch 4466 lbs: 100g patch
ORTHOPEDIC PROTOCOL
* DO NOT give morphine IV; it may cause histamine release. When using morphine, observe for nausea and vomiting, especially at higher doses. Also, observe for bradycardia; if found, treat with glycopyrrolate before induction. ** Doctor needs to be certified by medical director in order to perform epidurals. *** Pets with fentanyl patches should not be sent home with owner. Apply 12 hours before anesthesia if possible. Otherwise, apply as early as possible before induction.
sevoflurane delivery concentrations should be set at three percent using an oxygen flow rate of 3 L/minute for the first three minutes (3 percent/3 L/3 min). For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min, and sevoflurane concentration is adjusted, to effect. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation, or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.
Banfield Protocols
Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception and the Fractious Pet Protocol should be followed. Pre-anesthesia blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Maximum dose of acepromazine is 1.5 mg. Maximum dose of morphine is 2.5 mg for cats and 5 mg for dogs per administration. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Acepromazine should be prediluted to 1 mg/ml in a separate vial to allow proper dose administration. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol in healthy Pets following premeds is 1 to 2 mg/lb for dogs and 2 to 3 mg/lb for cats. Because of propofols rapid induction and rapid eliminationan approximately three- to five-minute window of durationthe technique of overpressure is required to assure a smooth transition to sevoflurane. For overpressure,

Postoperative morphine: Cat 0.05 to 0.15 mg/lb (max dose 2.5 mg) IM; dog 0.2 to 0.5 mg/lb (max dose 5 mg) IM; can be given when sevoflurane is discontinued as long as previous dose was at least four hours prior and the Pets cardiovascular system is normal and its temperature is greater than 98F. Repeat q four to six hours PRN for pain control. Postoperative ketoprofen at 0.9 mg/lb IM (single dose only) can be given when sevoflurane is discontinued as long as Pet is well-hydrated, has received intra-operative fluids, has no underlying renal or liver problems and no risk of significant hemorrhage exists. Do not confuse pain with dysphoria. If patient seems excitable or agitated, an additional dose of acepromazine may be necessary if it has been at least four hours since the previous dose and pulse quality and mucus membrane color are good. Give half of the premed dose of acepromazine SC-cat/IM-dog. Go home with NSAIDs and tramadol as appropriate for health status and pain level (See pages 24 to 26 for doses). Medications used for epidural pain control administration: (max volume for infusion is 6 mls) Preservative-free morphine (1.0 mg/ml). 0.05 to 0.1 mg/lb the volume is appropriate (no need to add saline). (See Epidural Analgesia, page 35.)
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Banfield Protocols
Ear Surgery Protocol (Total ear ablation, lateral ear resection, bulla osteotomy.)
Optional: Apply fentanyl patch. 12-24 hours prior to surgery.*
Premed: Acepromazine 0.025 mg/lb SC/IM (max dose 1.5 mg) plus morphine: cat- 0.050.15 mg/lb (max dose 2.5mg) dog- 0.20.5 mg/lb (max dose 5mg) **IM only. Wait 30 minutes. Induction: Telazol 0.51 mg/lb IV slowly to effect. (Telazol should be diluted with sterile water to a volume of 13 ml and given to effect to allow for intubation.) Maintenance: Sevourane 14% to effect, inhaled. Support: 2.5% dextrose in 0.45% NaCl at 510 ml/ lb/hr IV.
Postsurgical pain management: Morphine can be given at premed dose q 46 hrs if cardiovascular function is normal. Transition to: Cats: Ketoprofen 0.45 mg/lb 23 days. Dogs: Etogesic or Rimadyl 57 days.
Fentanyl patch dose: 11-22 lbs: 25g patch 22-44 lbs: 50g patch 44-66 lbs: 100g patch
EAR SURGERY PROTOCOL (other than Pinna)

* Note: Pets with fentanyl patches should not be sent home with owner. Apply patch 12 hours before anesthesia if possible. Otherwise, apply as early as possible before induction. ** DO NOT give morphine IV; it may cause histamine release. When using morphine, observe for nausea and vomiting, especially at higher doses. Also, observe for bradycardiaif found, treat with glycopyrrolate before induction. Induce healthy Pets for ear surgery with Telazol 0.5 to 1 mg/lb IV, to effect, rather than propofol. This helps avoid the need for higher doses of sevoflurane to prevent head movement during surgery. Telazol should be diluted with sterile water to a volume of 1 to 3 ml and given, to effect, to allow for intubation. Pets must be healthyother than the chronic ear problemsfor this protocol. If there are underlying health concerns (cardiac, liver, renal or other problems), patient should be stabilized, then appropriate premeds and induction agents used. Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception and the Fractious Pet Protocol should be followed. Pre-anesthetic blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Maximum dose of acepromazine is 1.5 mg. Maximum dose of morphine is 2.5 mg for cats and 5 mg for dogs per administration. Additional amounts of morphine at a pre-anesthetic dose may be given every four to six hours as needed for postsurgical pain control if cardiovascular function is normal. Dilute premedications administered SC or IM to a total volume of 0.5 to 3 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Acepromazine should be prediluted to 1 mg/ml in a separate vial to allow proper dose administration.
Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction. When using a dissociative for induction (Telazol or other dissociatives), do not use the overpressure technique. Begin with oxygen flow rates of 1 to 1.5 L/minute (rebreathing circuit) and a sevoflurane concentration of 1 to 1.5 percent. Overpressure may result in excessive anesthetic depth during the initial phase of general anesthesia. This is made worse by rapid respiratory rates. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours. If patient (usually dog) has a rough recovery, use 0.025 mg/lb acepromazine diluted IV given slowly, to effect (max dose 1.5 mg Ace) or diazepam at 0.05 to 0.1mg/ lb IV slowly to effect (maximum dose 5 mg). If unable to access IV, then administer Ace (0.025 mg/lb) IM or diazepam (0.1 mg/lb) IM. Postoperative ketoprofen at 0.9 mg/lb IM (single dose only) can be given when sevoflurane is discontinued as long as Pet is well-hydrated, has received intra-operative fluids, has no underlying renal or liver problems and no risk of significant hemorrhage exists.
Banfield Protocols

See Orthopedic Protocol.
Banfield Protocols
PAGE 81
CNS & Eye/Globe Protocol
Globe or eye injury Head trauma Epileptics
Diazepam 0.1 mg/lb IM (10 mg Maximum)
Wait 10 minutes Administer butorphanol 0.1-0.2 mg/lb IM (5 mg max).
Premed: already done. Induction: Propofol to effect 14 mg/lb IV. Maintenance: Sevourane 14% to effect, inhaled. Support: 2.5% dextrose in 0.45% NaCl at 510 ml/lb/hr IV. Monitor: Keep CO2 between 30-40 mm Hg. If CO2 is elevated there is higher seizure risk from increased intracranial pressure. If cerebral edema present, maintain CO2 between 2835 mm Hg to help decrease intracranial pressure.
CNS & EYE/GLOBE PROTOCOL

Acepromazine should be avoided in patients with a history of seizures. Monitor head trauma patients frequently for changing neurological status. Tonometry can be used to evaluate for increased intracranial pressure. Increased intraocular pressures can indicate increased intracranial pressure. In CNS cases, studies have indicated that use of IV fluids containing dextrose decreases the risk of seizures. Perform a complete physical examination and pre-anesthetic blood work before administering any pre-anesthetic or anesthetic drug. Fractious patients are the exception and the Fractious Pet Protocol should be followed. Pre-anesthetic blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Maximum dose of butorphanol is 5 mg. Additional amounts of butorphanol at a pre-anesthetic dose may be given every one to two hours as needed for postsurgical pain control. Maximum dose of diazepam is 10 mg. Dilute premedications administered SC or IM to a total volume of 0.5 to 3.0 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Allow 30 minutes for premeds to take effect before induction of general anesthesia. Assess cardiovascular parameters after premeds have taken effect and before induction. An ECG may be beneficial during cardiac assessment. If premeds are given more than three hours before induction, repeat premeds at half dose 30 minutes before induction.
Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol following premedication is 1 to 2 mg/lb for dogs and 2 to 3 mg/lb for cats. Because of propofols rapid induction and rapid eliminationan approximately three- to five-minute window of durationthe technique of overpressure is required to assure a smooth transition to sevoflurane. For overpressure, sevoflurane delivery concentrations should be set at 3 percent using an oxygen flow rate of 3 L/minute for the first three minutes (3 percent/3 L/3 min). For this technique to be effective, the respiratory rate must be near normal, or assisted ventilation is used to assure adequate intake and uptake of the inhalation agent. Following the initial three minutes, the oxygen flow is decreased to 1 to 1.5 L/min (rebreathing circuit), and sevoflurane concentration is adjusted, to effect. This may not be necessary in severely compromised Pets. Globe caution: bradycardia can occur when pressure is placed on the globe or traction is placed on the optic nerve. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.
Banfield Protocols

See Healthy Pet Protocol, or other protocol as appropriate to Pets health status and procedure completed.
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Banfield Protocols
Emergency Surgery Protocol
Stabilize & provide pain management such as butorphanol 0.10.2 mg/lb (max dose 5 mg). Next, determine health status.
If anesthesia is required to save life in less than 15 minutes, estimate protocol category. Otherwise, complete diagnostics & use appropriate protocol.
EMERGENCY SURGERY PROTOCOL

Stabilize prior to anesthesia: Manage shock. Manage arrhythmias. Provide pain management (butorphanol 0.1 to 0.2 mg/lb q 1 to 4 hr as needed). True emergencies requiring immediate anesthesia are rare. Most Pets will have a better outcome if stabilized before anesthesia or surgery. A true emergency requiring immediate surgery would include an airway obstruction or acute life-threatening hemorrhage. Gastric dilatationvolvulus (GDV) cases require stabilization and decompression before general anesthesia. They dont meet the definition of emergency as used in this protocol. Emergencies are surgical cases that require anesthesia within 15 minutes to save the patients life. Perform as complete a physical examination as possible. If the urgency of the situation precludes pre-anesthetic blood work, run it as the Pet is being examined and anesthetized. Pre-anesthesia blood work includes a CBC with differential and internal organ function screen. Maximum dose of butorphanol is 5 mg. With true emergency anesthesia, premeds, including butorphanol, may not have had time to take complete effect. Use the minimum amount of drugs for induction and the lowest sevoflurane percentage possible for the situation. Monitor Pet closely to see if Pet is getting deeper because of premeds, and decrease sevoflurane, if appropriate. Dilute premedications administered SC or IM to a total volume of 0.5 to 3.0 ml depending on the patients size. Dilute with sterile water. Volume dilution improves drug uptake. Assess cardiovascular parameters before induction. An ECG may be beneficial during cardiac assessment. If the patient is shocky, anesthesia is contraindicated. Correct shock before induction. In event of an emergency when correcting shock is not possible, mask induction with sevoflurane may be needed. If possible, consult with a medical advisor or director before proceeding with mask induction.
Avoid stress when utilizing mask induction; if heart rate increases by 25 percent or more during mask induction, allow patient to relax and administer appropriate IV induction agent. Propofol should be administered slowly, to effect, to minimize adverse cardiovascular effects. Bradycardia and apnea may develop after rapid administration. The average dose of propofol is often less than that required by healthy Pets. Err on the side of caution. Sevoflurane concentration necessary to keep these patients in a general plane of anesthesia is usually significantly lower than that required by a healthy Pet. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation or inadequate oxygen flow rate. Antibiotics other than cefazolin must be administered a minimum of one hour before anesthesia or following complete recovery. Use saline without dextrose as the IV fluid choice in critical cases (cardiac/pulmonary/abdominal). If cardiac arrest occurs, any drug can be administered through the existing IV with decreased concern regarding interaction of cardiac drugs with fluid components. Critically ill patients may be slow to recover from anesthesia. Monitor and document TPR and other vitals frequently and provide supportive care as necessary. It is best to avoid vaccinations in association with general anesthesia. If vaccines must be given, wait until the Pet has fully recovered for at least two hours.
Banfield Protocols

See protocol most appropriate for Pet's health status and procedure performed.
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Premed: Glycopyrrolate 0.005 mg/lb IM plus diazepam 0.1 mg/lb IM plus butorphanol 0.10.2 mg/lb IM. Pediatric Pet Protocol (<16 weeks of age) Wait 30 minutes. Induction: Propofol to effect 14 mg/lb IV. Maintenance: Sevourane 14% to effect, inhaled. Support: 2.5% dextrose in 0.45% NaCl at 25 ml/lb/hr IV. Postoperative pain management: Butorphanol 0.10.2 mg/lb IM q 24 hours pm.
PEDIATRIC PET PROTOCOL

Puppies and kittens develop hypothermia, hypoglycemia and dehydration more quickly. It is unnecessary to withhold food from nursing puppies and kittens before anesthesia. In weaned puppies and kittens, fasting should not be for more than one or two hours. Perform a complete physical examination (with particular attention to the cardiovascular and respiratory systems) and pre-anesthetic blood work prior to any pre-anesthetic or anesthetic drug administration.
of ageconsequently, puppies and kittens have a greater sensitivity to highly protein-bound medications. BUN and urine-specific gravity levels are lower in puppies and kittens than they are in adults because renal function is undeveloped. Puppies and kittens have lower blood pressures, stroke volumes, and peripheral vascular resistance but higher heart rates, cardiac outputs, plasma volumes, and central venous pressures than adult cats and dogs. The pediatric heart is less able to increase the stroke volume (force of contraction) and, therefore, cardiac output depends primarily on heart rate. Bradycardia is defined as <150 beats/min and should be addressed quickly. Because cardiac output in puppies and kittens is heart-rate dependent and they inherently have high vagal tone, administration of an anticholinergic is necessary before induction of general anesthesia. This also decreases respiratory tract secretions, which reduce the potential for airway obstruction and/or laryngotracheal aspiration. They may not be effective in Pets <2 weeks of age. Diazepam requires hepatic metabolism, and duration of action may be prolonged in Pets <8 weeks of age. It produces good muscle relaxation with minimal CNS and cardiovascular depression, but it does have a dose-dependent respiratory depressant effect and may cause hypoventilation or apnea, so careful monitoring of the respiratory system is necessary. In debilitated patients, it may be best to avoid its administration. The oxygen demand of puppies and kittens is two to three times that of adult dogs and cats. The respiratory rate must be two to three times greater than the adult rate to meet the minute ventilation necessary for the greater oxygen demand. A high respiratory rate during anesthesia must be maintained. This will also cause a more rapid induction and recovery inhalation anesthesia due to the increased rate of exchange of gases in the lungs. Intermittent positive-pressure ventilation is likely needed to prevent hypoventilation and atelectasis. Airway pressures should not exceed 15 cm H20. Extreme care is required to prevent lung trauma and pneumothorax. Pets >4 weeks of age can be allowed to ventilate spontaneously. Allow 30 minutes for premeds to take effect prior to induction of general anesthesia.
Banfield Protocols
The normal heart rate of puppies and kittens is 200 or more beats per minute. Normal respiratory rate is 15 to 35 breaths per minute. Respiratory system is best evaluated by observation of the rate, rhythm and character of breathing. Normal body temperature for Pets <2 weeks of age is 96 to 97F, which increases to 100F by 4 weeks age. Dehydration occurs rapidly in puppies and kittens. Hydration status can be assessed by moistness of mucus membranes, position of eyes in their orbits, heart rate, character of peripheral pulses and capillary refill time. In puppies and kittens <6 wks of age, urine should be clear or colorless, and any color tint indicates dehydration. Skin turgor is not useful for assessment of hydration status in puppies and kittens <6 weeks of age. Pre-anesthesia blood work includes a CBC with differential and internal organ function screen. Perform these tests within 48 hours of anesthetic induction. Sample size may be limited, therefore PCV, evaluation of white blood cell morphology, blood glucose and BUN are the priorities. A complete urinalysis may be helpful as well. High PCVs are common the first few days of life. These levels decrease to 27 percent by 7 weeks of age and thereafter increase to normal adult levels. Puppies and kittens have higher white blood cell counts in the first few days of life. By 3 weeks of age, white blood cell counts decrease, then peak again at 7 weeks of age. Albumin levels in puppies <4 weeks of age are lower than adult levelsadult levels are attained by 8 weeks
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Banfield Protocols
Assess cardiovascular parameters after premeds have taken effect and prior to induction. Propofol should be administered as a slow bolus over one to two minutes until desired effect is achieved. Bradycardia, hypotension and respiratory depression may develop after rapid administration. Care should be taken in puppies and kittens <8 weeks of age. Debilitated patients may be mask induced with sevoflurane. Intubation may be difficult in small patients. Care must be taken to avoid laryngeal trauma, which may induce swelling. If intubation cannot be performed, a tightly fitting mask can be used to minimize dead space. If running sevoflurane at 4 percent or above, look for system leaks, improper intubation, or inadequate oxygen flow rate. During prolonged procedures, blood glucose should be checked periodically. Antibiotics other than cefazolin must be administered a minimum of one hour prior to anesthesia or following complete recovery.
If vaccines must be given, wait until the Pet has fully recovered for at least two hours.
Reference: Hoskins J. Veterinary Pediatrics: Dogs and Cats from Birth to Six Months. Philadelphia, Pa.: W.B. Saunders. 3rd ed:525-547.

Postoperative butorphanol at 0.1 to 0.2 mg/lb IMmaximum 5 mg per each dosecan be given when sevoflurane is discontinued as long as previous dose was at least one hour prior and the Pets temperature is greater than 98F. Continue butorphanol at 0.1 to 0.2 mg/lb IMmax 5 mg/dose q one to two hours PRN if ketoprofen alone is not controlling pain. Buprenorphine (See page 24) can be substituted for butorphanol for post-op pain management. Dysphoria is common with butorphanol, especially with multiple doses. If Pet is dysphoric, diazepam (0.05 to 0.1 mg/lb IV maximum dose 5mg) can be given slowly, to effect, and monitor temperature and cardiovascular function closely. Go home pain meds: Avoid NSAIDs and use burtophanol in syrup as appropriate for health status and pain level.
Banfield Protocols
Paige, Jennie, Veronica and Laura
Banfield Protocols
PAGE 85
ANESTHESIA MONITORING AND EMERGENCY PROTOCOL

Procedures to be used during anesthesia: Monitoring by surgical assistant required. Record pulse, pulse quality, RR, O2 saturation and ECG q 5 to 10 minutes; record temperature q 10 to 15 minutes.
Anesthesia Monitoring and Emergency Protocol Pulse Quality Monitor femoral pulse and MM every 3 to 5 minutes. Oxygenation Monitor pulse ox and respirations continuously. Decreased saturation (pulse ox reading <94) End Tidal CO2 Monitor continuously (Optional).
ECG Monitor ECG and HR continuously.
Poor or diminishing pulse quality.
VPC
Banfield Protocols
Increase uid to 1040 ml/lb/hr Decrease sevo. Increase 02 to 2 L/ min, check pulse ox and MM to verify oxygenation.
Decrease Sevo. Increase 02 to 2L/ min. Start ventilating. Increase uid to 10-40 ml/lb/hr. Check pulse quality - ventilate Pet 2x to clear CO2.
Decrease sevo 50%. Increase 02 to 2 L/min. Increase uid to 10-40 ml/lb/hr. Look for causes of pain If no improvement in 1 min. give lidocaine bolus Dog: 0.51 ml/10 lbs IV Cat: 0.060.1 ml/10 lbs IV Given slowly to effect. Dog Start lidocaine drip for maintenance at 2 ml/lb/hr. Decrease drip rate if bradycardia develops.*
2nd heart block or bradycardia: Lg Dog < 60/min Med dog < 80/min Sm Dog < 100/min Cat < 120/min
CO2
Decrease sevo. Increase uid to 1040 ml/lb/hr.
> 50 ventilate patient. < 35 stop hyperventilation.
If no improvement within 2 minutes, check ECG. If bradycardia/2nd heart block or VPC, see appropriate emergency protocol. If ECG normal and pulse quality still decreased, administer Neo-Synephrine intranasal: Large dog: 14 drops. Small dogs and cats 12 drops. Increase uids to 1040 ml/lb/hr. If positive response and no VPCs, can repeat dose. If no improvement in pulse quality within 2 minutes proceed. Ephedrine (0.05 to 2.5 mg/lb) IV. Dilute 0.1 ml ephedrine in 0.9 ml saline to = 5 mg/ml. Give 0.1 ml/10 lb IV slowly Dose every 15-20 minutes PRN. Limit of 2 doses. If no response, give dobutamine 0.52.5 g/lb/min in saline drip.** Dobutamine Microdrip: 6.5 lb = 1 drop per 4 sec 12 lb = 1 drop per 2 sec 25 lb = 1 drop per sec 50 lb = 2 drops per sec 75 lb = 3 drops per sec 100 lb = 4 drops per sec
If no improvement glycopyrrolate 0.005 mg/lb IV or IM. If no improvement, go to Atropine
Atropine 0.01 mg/lb IV Give slowly over 30 seconds & volume dilute if needed.
Cat Start lidocaine drip for maintenance at 0.30.5 ml/lb/hr. Decrease drip rate if bradycardia develops.*
* Lidocaine drip = 1000 ml saline plus 50 ml of 2% lidocaine = 1 mg/ml. Lidocaine drip cannot be used for volume loading, so a second IV catheter & line will be needed.
Tachycardia: Lg dog > 120/min Med dog > 140/min Sm dog > 140/min Cat> 140/min
With movement: increase sevourane.
If in arrest, use epinephrine (1:1,000) 0.1 ml/10 lb (See CPR Protocol.)
Without movement: Decrease sevo. Increase uid to 1040 ml/lb/hr & check pulse quality.
Begin CPR.
Watch for VPCs.
** 25 dobutamine mg in 1 liter of normal saline via microdrip. 25 mg/1000 ml = 0.025 mg/ml = 25 ug/ml; 25 lb dog @ 1 ug/lb/min = 1 ml/minadminister 1 drop/sec (via microdrip) monitor pulse and ECG. As pulse increases, decrease Dobutamine. If VPCs and tachycardia develop, decrease Dobutamine.
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Banfield Protocols
CPR PROTOCOL
Cardiopulmonary arrest is defined as the abrupt and unexpected cessation of spontaneous and effective ventilation and circulation. This can be the natural ending of a full life or the result of trauma or disease states. If cardiopulmonary arrest is because of a potentially reversible traumatic or medical condition, then prompt application of sound cardiopulmonary resuscitation (CPR) techniques while addressing the underlying cause of the arrest may allow restoration of life signs. Effective CPR requires a highly trained, efficient and coordinated team, appropriate monitoring devices and medications, and prompt application of CPR techniques. Even with aggressive and effective CPR, survival rates are lowless than 10 percent. Controversy exists as to the best CPR techniques and protocol. Therefore, we have combined recommendations from many sources to produce a reasonable CPR protocol that will benefit the greatest number of patients and utilizes equipment, techniques and medications that should be available in all of our hospitals. The goal of the following CPR protocol is to provide an outline for closed-chest CPR in dogs and cats. This protocol is a template. To be effective, it will require training of a team of doctors and PetNurses who can work together efficiently. Recommended team training should include: 1. All doctors and paraprofessionals must familiarize themselves with the protocol. 2. Develop a hierarchy of who will be running the code according to who is available. The doctor present will usually be running the code, but a lead PetNurse may need to initiate the code.
3. Have frequent drills with your team to rehearse CPR. Consider bringing in a stuffed animal as the dummy. This should include the leader assigning duties and directing the code. 4. Rotate teams and individual responsibilities during the code drill so that each team member is comfortable doing each job during a code. 5. Determine division of labor during a code by the number of associates available. A person may have more than one job responsibility. Assigned roles of responsibility include: Running the code. Ventilation. Chest compressions. Rotate the person doing compressions every three to four minutes to keep up adequate strength of compressions. IV catheter placement, fluid and medication administration. Gopher. Monitoring. Recording. This CPR protocol does not replace the Emergency Protocol on the Anesthetic Monitoring Flow Chart. The CPR protocol only applies to anesthetic cases once cardiopulmonary arrest is noted.
Banfield Protocols
Cardiopulmonary arrest
Cardiopulmonary arrest: Drug choice is based on ECG rhythm. NOTE: All ECGs are recorded at 50 mm/sec and 1 cm = 1mv.
Banfield Protocols
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Cardiopulmonary Arrest
Ventricular tachycardia
Lidocaine Evaluate for response, reassess patient.
No respiration. Pulse present.
No respiration. No pulse. No heartbeat.
Sinus tachycardia
*
Establish airway. Intubate. Ventilate with oxygen. (connect to anesthetic machine with oxygen only).
IV uids assess blood volume continue to ventilate.
Establish airway. Intubate. Ventilate with oxygen. (connect to anesthetic machine with oxygen only)
Evaluate for response, reassess patient.
Cardiac compressions 100-120/min
Normal rate & rhythm
Monitor, provide: supportive care. Evaluate for response, reassess patient.
Banfield Protocols
Connect to monitors (continuous ECG & pulse ox). Place IV catheter. Start IV uids.
Connect to monitors (continuous ECG & pulse ox) Place IV catheter. Start IV uids. Bradycardia PetNurse/assistant duties (Doctor or lead PetNurse to assign roles) Ventilations. Compressions. Attach monitors (ECG, pulse ox, etc.) Evaluate/monitor patient. Place & maintain IV catheter. Administer drugsrecord doses, time, Pet response. Supportive care (lube eyes, heating pad, etc.) Gopher.
Diagnose & treat underlying disorders.
Atropine 1st epinephrine: 2nd if necessary.
Evaluate for response, reassess patient. Asystole
Reassess patient.
Atropine 1st epinephrine: 2nd if necessary. Evaluate for response, reassess patient.
MONITORING INCLUDES Heart rate. ECG rhythm. Pulse quality/decits. Capillary rell time. Respiratory rate (assisted or spontaneous). Pulse oximetry. Temperature. Blood volume(PCV/TP, hemorrhage, pulse quality, heart rate). Pupillary light response & other cranial nerve reexes (note any changes & presence or absence of reexes). Level of consciousness. Urine production (place urinary catheter if stable monitor output). Blood glucose.
Electromechanical dissociation Any and all pulseless rhythms Difcult to rule out weak ventricular function Dog: femoral pulse disappears with a systolic pressure of 60 mm of Hg and heart sounds disappear below a systolic blood pressure of 50 mm of Hg. Ventricular brillation
Epinephrine: 1st dexamethasone: 2nd if necessary. Evaluate for response, reassess patient.
Epinephrine: 1st Lidocaine bolus: 2nd if necessary. Evaluate for response, reassess patient.
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Banfield Protocols
*
VENTILATION (100% Oxygen)
Establish airway (laryngoscope, endotracheal tube, tie in place. Connect to Anesthesia Machine with 02 only Give 2 long breaths (1.5-2 seconds each) Continue at 10-20 breaths per minute (2 for every 15 chest compressions) Dog: 15-20 cm H2O Cat: 12-17 cm of H2O Chronic lung disease: < 12 cm of H2O
IV DRUGS
Always bolus 10-30 ml 0.9% NaCl after each medication & wait 30 seconds to 2 minutes for response; repeat drugs doses as necessary Atropine IV (0.54 mg/ml) 0.01-0.02 mg/lb (0.2-0.4 ml/10 lb) Epinephrine IV (1:1000 - 1 mg/ml) Start with low dose and progress to high dose Low dose = 0.005 to 0.01 mg/lb (0.05-0.1 ml/10 lb) High dose = 0.1 mg/lb (1 ml/10 lb)
EXTERNAL CHEST COMPRESSIONS

<10 lb, lateral recumbency Encircle chest with hands at level of 4th-5th intercostal space 100-120 compressions/minute Should decrease chest diameter by 25-33% >15 lb, lateral recumbency (stand with Pet's spine closest to you) Center over highest portion of chest wall at level of 4th-5th intercostal space 100-120 compressions/minute Should decrease chest diameter by 25-33% Augmenting Techniques Abdominal compression alternating with chest compressions (gentle to avoid damage to abdominal organs) Counter pressure (sand bag over mid-abdomen) Wrapping hind limbs
Lidocaine IV (2% solution = 20 mg/ml) Monitor with ECG Start with bolus and if successful convert to CRI Dog bolus: 1-2 mg/lb (0.5-1 ml/10 lb) Cat bolus: 0.125-0.25 mg/lb (0.06-0.125 ml/10 lb) Lidocaine CRI (Lidocaine drip - 1 L saline and 50 ml 2% Lidocaine) Dog: 2 ml/lb/hr to control VPCs. Decrease drip rate if bradycardia develops. Use second IV catheter for administration Cat: 0.3 to 0.5 ml/lb/hr to control VPCs. Decrease drip rate if bradycardia develops. Use second IV catheter for administration. Dexamethasone sodium phosphate IV (4 mg/ml) 2 mg/lb (5 ml/10 lb)
Banfield Protocols
FLUIDS
Place largest catheter possible central preferred, i.e. jugular catheter 0.9% NaCl Give following dose as initial bolus, then reassess for ongoing rate. Dog: 20 ml/lb Cat: 10 ml/lb Adjust continued uid therapy for underlying disease, i.e. congestive heart failure. Dog: 20-40 ml/lb/hr Cat: 10-20 ml/lb/hr Assess need for colloids (TP<3.5, Alb. <1.5, poor pulse quality w/ adequate crystalloid administration, need for rapid volume expansion. Establish second IV line) Hetastarch: Dog: 4.5-10 ml/lb over rst hr. in increments of 2.5 ml/lb/5-10 min. Cat: 2.5-4.5 ml/lb over rst hr. in increments of 2.5 ml/lb/510 min. Fresh Frozen Plasma: 2.5-4.5 ml/lb at 10 ml/lb/hr Oxyglobin: Dog: 4.0-13.5 ml/lb at 4.0 ml/lb/hr or increments of 2.5 ml/ lb 5-10 min Cat: 2.5-7.5 ml/lb at 1 ml/lb/hr or increments of 2.5 ml/lb/510 min Assess need for oxygen carrying uids (HCT or PCV<25% or signicant hemorrhage. Establish second IV line) Packed red blood cells 2.5-4.5 ml/lb at 5-10 ml/lb/hr Dog: no need for cross match with rst transfusion Cat: always blood type or cross match Fresh whole blood 4.5-10 ml/lb at 5-10 ml/lb/hr, cross match as above Oxyglobin: (as above)
Sodium bicarbonate IV (8.4%, 1 mEq/ml) Monitor with ECG Consider after 10-15 minutes of unsuccessful CPR Consider with known acidosis 0.2-0.45 mEq/lb (2-4.5 ml/10 lb). Give slowly over 5 minutes Repeat every 10-15 minutes of unsuccessful CPR Hyperventilate post administration for 30 seconds INTRATRACHEAL DRUGS Atropine, epinephrine, lidocaine Double the IV dose Administer through a red rubber catheter advanced beyond the end of endotracheal tube Follow with 5-10 ml 0.9% NaCl to ush drug through red rubber catheter Hyperventilate after administration for 10 seconds
POST RESUSCITATION
Monitor (See ow chart) Support organ systems. Consider all appropriate measures Respiratory: supplemental oxygen (nasal or e-collar) Cardiac: supplemental oxygen (nasal or e-collar), furosemide, lidocaine, Dobutamine, IV uids, continued positive pressure ventilation with oxygen Neurologic: supplemental oxygen (nasal or e-collar), continued ventilation with oxygen to reduce carbon dioxide levels, Mannitol, corticosteroids, furosemide, Dobutamine Renal: continued uid therapy. If normovolemic and normotensive and oliguric (less than 0.45 ml of urine/lb/hr produced) consider Mannitol or furosemide with or without a Dobutamine drip - Dogs Only Drugs: Mannitol (0.25-0.5 g/lb IV over 20 minutes). Furosemide (1-2 mg/lb IV), Dobutamine (2-10ug/lb/min IV: 25 mg in 1L of saline via microdrip = 25 micrograms/ml. Monitor pulse and ECG - as pulse increases, decrease Dobutamine. If VPCs or tachycardia develop, decrease drip rate). Lidocaine CRI, corticosteroids (dexamethasone SP 2-5 mg/lb IV or methylprenisolone Na succinate 5-15 mg/lb IV), dopamine (Dogs only) 0.22-1.4 micrograms/lb/minute (dopamine 40 mg/ml add 1/2 ml = 20 mg to 1 L 0.9% NaCl = 20 micrograms/ml, microdrip set = 60 drops/ml, 20 lb dog at 1 microgram/lb/minute = 20 micrograms/minute = 1 drop every 3 seconds), broad spectrum antibiotics. Consider referral for 24-hour care when stable for transport.

INTRACARDIAC DRUGS NOT APPROPRIATE DO NOT ADMINISTER
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Patient Anesthesia Monitoring Form
Banfield Protocols
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Banfield Protocols
Dr. Hamilton, Katie, Bob and Simon
Fluid Therapy in Pets

Two major categories of fluids are administered to Pets: crystalloids and colloids. A crystalloid is a water-based solution with small molecules that are permeable to capillary membranes. The crystalloid solutions currently used in the Banfield practice are: 0.9 percent sodium chloride (0.9 percent NaCl). 0.45 percent sodium chloride with 2.5 percent dextrose (2.5 percent dextrose/0.45 percent NaCl). Normosol-R A colloid fluid is a water-based solution with both small molecules that are permeable to the capillary membrane and large molecules that cannot cross the capillary membrane. Natural colloids consist of plasma proteins from donor animals and are administered as fresh frozen plasma, packed red blood cells or whole blood. Synthetic colloids are man-made large molecules dissolved in normal saline. The synthetic colloid that Banfield currently carries is hydroxyethyl starch, otherwise known as hetastarch. Oxyglobin is still not routinely available, so it is not discussed. Normosol-R provides electrolytes and buffers in concentrations similar to normal plasma. Normosol-R is called a replacement fluid. It is important to remember that even though Normosol-R is balanced and contains potassium typical of normal plasma levels, it will not prevent ongoing potassium loss or correct hypokalemia. Potassium supplementation is often needed (i.e., severe gastroenteritis, chronic renal failure). Monitoring the patients electrolyte levels is the best way to determine the appropriate potassium supplementation. Serum Potassium (mmol/L) Below 2.0 2.02.5 2.63.0 3.13.5 Potassium Chloride Added to Liter of Fluid 80mEq 60mEq 40mEq 28mEq Maximum Fluid Infusion Rate (ml/kg/h) 6 8 12 16
Section 3:
CRYSTALLOIDS
Crystalloids are used primarily for interstitial volume replacement and maintenance fluids. In most clinical situations, rehydration and resuscitation with crystalloids is best accomplished by using an isotonic, balanced electrolyte solution such as Normosol-R.
Both 0.9 percent NaCl and 2.5 percent dextrose/0.45 percent NaCl solutions are also isotonic, but they are not balanced since they contain only sodium, chloride and water. They can be used as replacement fluids in select situations where Normosol-R is not appropriate, such as hyperkalemia or alkalosis. In many situations, potassium supplementation may be necessary.
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The following reference table is a guide for potassium supplementation. Selection of the appropriate fluid type and fluid rate for a patient should be based on the needs of the patient. Fluid rate calculation for a patient is based on maintenance needs, plus dehydration deficit, plus ongoing losses. Maintenance fluid volume for Pet: Dehydration deficit 2.2 ml/kg/hr (1 ml/lb/hr) % dehydration x B.W. (kg) = L of fluid (then decide correction within 1224 hours to get ml/hr rate) This is usually based on an estimate of fluid loss from vomiting, diarrhea and urine. 10 lb Pet with 5% dehydration vomiting 5 x daily (~ 30 ml/vomit) and urinating ~ 100 ml/day 10 ml/hr 0.05 x 5 kg = 0.25 L (250 ml); if want to correct dehydration in 12 hours 250/12 = 20 ml/hr or in 24 hours 250/24 =10 ml/hr {(30 ml x 5) + 100 ml}= 250 ml/24 hr = 11 ml/hr 41 ml/hr for 12 hrs, then 21 ml/hr next 12 hrs
Cross-matching should be performed for animals receiving blood products containing red blood cells. In normovolemic patients, the recommended infusion rate for whole blood or plasma products is 6 to 22 ml/kg/day. In hypovolemic patients, the rate should not exceed 22 ml/ kg/hr. For patients with compromised cardiac function, the rate should not exceed 4 ml/kg/hr. All transfusions should be completed within four hours because of the risk of bacterial growth in blood maintained at room temperature for a prolonged period of time. Patients who are receiving transfusions should be monitored during the process to ensure early detection and prompt treatment of a transfusion reaction. Rectal temperature, heart rate and respiratory rate should be recorded every 10 minutes during the first 30 minutes, and every 30 minutes thereafter. Monitor also for tachycardia, hyperthermia/fever, angioedema, hypotension, vomiting, diarrhea, urticaria, hemoglobinuria and hemoglobinemia. Any of these symptoms or changes in vital signs can be an indication of a transfusion reaction. At this point, the transfusion should be stopped until the patient is evaluated further and treated if necessary. Note: Pulse oximeter readings are not affected by the administration of canine blood containing Oxyglobin (Hb-200). Synthetic colloids (hetastarch) can be used to increase central oncotic pressure and avoid the problems encountered with rapid natural colloid infusion. They can also be used in conjunction with whole blood or plasma. They are not, however, to be considered a substitute for blood products when albumin, red blood cells or coagulation proteins are needed. Synthetic colloids should be used with caution and at reduced dosage rates in patients with congestive heart failure and in those with renal disease. Hetastarch can be used for traumatic or hypovolemic shock. It can be used in combination with plasma or whole blood for ongoing hemorrhage from traumatic loss, or disseminated intravascular coagulation (DIC). Dose: Give IV in increments of 5 ml/kg (2.25 ml/lb), over five to 10 minutes, to effect, up to 40 ml/kg (18 ml/lb) total dose. Hetastarch has a moderate colloid effect for approximately 24 hours.
Ongoing fluid loss
Example:
Maintenance fluid + Dehydration deficit
+ Ongoing fluid loss Fluid rate
It is important to evaluate the patient daily to determine if the fluid rate is meeting the patients needs. Electrolytes should also be evaluated on a regular basis so that imbalances can be corrected.
COLLOIDS
Colloids are primarily intravascular volume-replacing fluids. When serum albumin levels are less than 2.0 g/dl, colloids are needed to support oncotic pressure. Natural colloids contain more than just oncotic proteins. Fresh whole blood contains red blood cells, coagulation factors, platelets, albumin, fibrinogen, globulins, white blood cells and antithrombin. A starting dosage is 10 to 22 ml/kg. Packed red blood cells contain red blood cells only. Starting dose is 10 ml/kg (5 ml/lb). Fresh frozen plasma (FFP) contains coagulation factors, albumin, fibrinogen, globulins and antithrombin. Starting dosage for FFP is 6 to10 ml/kg. Blood products should always be administered warm (never exceed 37C) with an in-line blood filter.
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SHOCK
Shock is a multisystemic response to a systemic injury or illness that produces inadequate tissue perfusion and energy production. Causes of shock include severe hypovolemia, trauma, sepsis, heat stroke, hypoglycemia, heart failure, malnutrition or any end-stage visceral organ failure. Aggressive volume resuscitation is indicated in the treatment of hypovolemic, traumatic or septic shock. Crystalloid fluids such as 0.9 percent NaCl or Normosol-R should be used initially. Volumes 1.5 to 3 times the calculated blood volume of the Pet (blood volume of the dog is 80 to 90 ml/kg; blood volume of the cat is ~ 60 ml/kg) may be required to restore cardiovascular values to acceptable levels. For dogs, a starting dose is 90 ml/kg (40 ml/lb). Give half of the calculated volume as fast as possible, then reassess. For cats, a starting dose is 40 ml/kg (18 ml/lb). Give half of the calculated volume as fast as possible, then reassess. Two or three large-gauge intravenous catheters may be required to achieve these fluid volume rates. Synthetic colloids can be valuable for volume resuscitation. A dose of 10 to 20 ml/kg for a dog and 5 to 10 ml/kg for a cat during the first hour of treatment is useful for reducing calculated fluid volume in the resuscitation protocol. Whole blood or plasma should be administered in quantities sufficient to maintain the packed cell volume (PCV) above 25 percent and the total plasma protein (TPP) concentration above 3.5 g/dl. Blood products should be run through a separate IV line as previously discussed. Oxygen therapy is indicated in all shock categories and may be administered by face mask, oxygen enclosure, nasally (3 to 10 L/min) or transtracheally.
IV drip set. 22, 20 or 18-gauge short spinal needle (order through Banfield Direct) is preferred to prevent bone plugs, however syringe needles of the appropriate gauge can be used. Surgical gloves. Most critically ill Pets will not need to be sedated for intraosseous catheter placement. If sedation is necessary, use diazepam 0.1 mg/lb intramuscularly (IM) cats/dogs (max dose of 10 mg) plus butorphanol 0.1 to 0.2 mg/lb (max dose of 5 mg) IM. (For exotic patients, please refer to the Anesthetic Considerations for Small Exotic Pets Protocol, starting on page 95 and proceed with the steps for the particular species or class.) Shave and perform a surgical prep of the area over the insertion site. See diagram for recommended sites. After surgical prep, a glove cover can be used to create a clean field over the insertion site. Block the skin over the site and the deep tissues, including the periosteum, with lidocaine. Calculate the lidocaine dose carefully to avoid toxicity due to overdose. The maximum lidocaine dose for a local block is 2 mg/lb. Lidocaine is a 2 percent solution (20 mg/ml). If the site cannot be easily palpated because of fat/ muscle tissue or tough skin, make a small stab incision to facilitate insertion of the needle into the bone. Note: Difficult insertion can result in a bent/dulled needle or tissue trauma. Insert the needle, with the stylet in place (see diagram for location and orientation of the needle), into the trochanteric fossa of the femur, greater tubercle of the humerus or proximal tibia. Use moderate direct pressure or, if necessary, a back and forth screwing motion through the cortex. Puppies and kittens have very soft bones, and very little pressure is needed.
INTRAOSSEOUS ROUTE FOR FLUID THERAPY

It is often very difficult or impossible to deliver fluid therapy intravenously to pediatric patients, other small exotics and Pets in shock. In these cases, where peripheral veins are small and collapsed, it is very important to supply the patient with fluids. Placement of an intraosseous catheter is a simple and lifesaving procedure that allows us to give Pets the same care we want for ourselves. Materials: Intravenous (IV) fluids.
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Once the needle is in the marrow cavity there should be no resistance. If you do meet resistance you are hitting cortical bone and you may need to withdraw the needle partway and redirect it. Continue through the cortical bone to reach the marrow cavity or withdraw the needle a few millimeters to see if you are hitting the cortical bone on the opposite side of the marrow cavity. To confirm correct placement, remove the stylet, attach a sterile 3 ml syringe and aspirate. A small amount of marrow should be visible in the hub. Marrow is not always retrieved, especially in exotics. If the needle is well-seated you should be able to move the limb by moving the hub of the needle and sterile fluid should flow easily into the needle with no subcutaneous buildup of fluid. Secure the hub of the needle with tape and/or suture. E-collars are highly recommended to prevent patient aggravation of the site. Attach IV fluids. Anything that can be administered IV (with the exception of chemotherapeutic agents), can also be administered via intraosseous (IO) catheter. Follow the same dose and fluid rate as used for IV. If fluids are not to be continuous, a catheter male adaptor plug may be inserted and the site padded with gauze and vet-wrapped to protect the hub.
Intraosseous catheters may be left in place for up to 72 hours in a critically ill patient. The IO catheter must be pulled if the patient becomes active and bends the needle. Possible complications: Infection resulting in cellulites, subcutaneous abscess or osteomyelitis. Proper sterilization and prep of area before catheter placement will greatly reduce the chance of infection. Extravasation of fluid around the puncture site. This will be absorbed once fluids are stopped. Needle breaks off in the bone. As long as there is no infection or tissue irritation, this is unlikely to be a problem. If a portion of the needle is in the subcutaneous space, then you can attempt retrieval with a cut-down. Possible reasons for therapeutic failure: Misplacement, bending or clogging of the needle. Puncture through the bone. Replacement of the marrow cavity with fat or fibrous tissue.
Linda and Dido
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Anesthetic Considerations for Small Exotic Pets
Danielle and Featherhead
Anesthetic Considerations
Avians, Reptiles, Ferrets, Rabbits, Guinea Pigs, Chinchillas, Rodents, Hedgehogs INTRODUCTION
Exotic Pet anesthesia is essentially the same as feline and canine anesthesia. However, application requires modification of apparatus due to small patient size, recognition of variable drug sensitivities, species idiosyncrasies, challenges of restraint and monitoring limitations. The six basic steps of anesthesia apply to exotic Pets as well as cats and dogs. 1. Pre-anesthetic evaluation: Client education, Pet health status, laboratory information. 2. Pre-anesthetic preparation: Fasting, stabilization of systemic status, fluid and oxygen supplementation, equipment and staff training, premedication, venous access if appropriate. 3. Monitoring: Cardiopulmonary, end-tidal CO2 monitoring, blood pressure (CO2 and BP ideal, but not currently available at all hospitals), pulse oximetry, temperature, plane of anesthesia, reflexes, hydration status. 4. Induction: Provides a smooth transition into unconsciousness and allows airway to be established and secured. 5. Maintenance: Temperature maintenance, prevention of hypoglycemia, hypovolemia and hypothermia. 6. Postoperative care: Recovery, temperature maintenance, pain control, fluid balance. Proper application of the six steps must address the following issues: Evaluation of medical history, physical state and laboratory data. Stabilization of physiological status before induction of anesthesia. Minimization of anesthetic timepreparation is key. Correct anesthetic drug dose selection (consider health status, species, breed, and pre-existing conditions and complications). Maintenance of patient airway, oxygen support and monitoring. Monitoring and support of cardiovascular function (fluids and adrenergic drugs). Monitoring and support of body temperature (use of supplemental heat to reduce heat loss).
Section 4:
for Small Exotic Pets
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Continued monitoring and support until complete recovery. Analgesic/tranquilizer to decrease pain, stress and excitement during induction/recovery. Preparation (adequate staff training) for normal and complicated or adverse outcomes.
Become familiar with common ailments of each species. Evaluate any pre-existing conditions or clinical signs including anemia, cyanosis, cachexia or obesity, anorexia (fasting), icterus, weakness or central nervous system (CNS) depression, dehydration, ascites, respiratory abnormalities, tissue trauma and clotting abnormalities. Use appropriate caution in Pets with hepatic, renal, or other compromise. Stabilize systemic status if possible, including treatment for pain if appropriate. Perform pre-anesthetic blood work whenever possible. This includes complete blood cell count (CBC)/differential and a chemistry profile. It may not be possible to obtain adequate blood sample volumes from very small Pets. However, a sample adequate to perform a packed cell volume (PCV) total protein (TP) and blood glucose is usually obtainable from all but the very smallest Pets. Consider urinalysis, fecal examination and other blood tests as appropriate to the case. The current in-house blood chemistry machine will run chemistries on rabbits, ferrets, many avians, reptiles and rodents. The in-house CBC machine will run CBCs on rabbits and ferrets. You will have to refer to a text for ferret normals. Rabbit normal cards are available for the in-house Scil/Heska machines. A rabbit card for CBCs can be obtained by submitting a purchase requisition form to Medical Resources (See instructions in SmartHelp). In most cases, CBCs for reptiles and avians will need to be sent to a reference lab. A manual count can be performed in-house if you have skill in reading avian and reptile blood smears. Address any pre-anesthetic blood work abnormalities before proceeding with anesthesia. When emergency surgery is truly necessary, stabilize the patient as much as possible before anesthesia. Situations where surgery is required before any stabilization has been performed are rare.
Special considerations for exotic Pet anesthesia Anesthetic Considerations for Small Exotic Pets
The small body size of many exotic mammals and avians equates to increased metabolism compared to dogs and cats, while reptiles generally have slower metabolism. This variability has a significant impact on anesthetic considerations. Metabolism levels may increase or decrease drug requirements or duration of action compared to dogs and cats, increase the risk of hypoglycemia due to fasting, and increase oxygen requirements in most species. Most exotic Pets are extremely sensitive to any period of apnea or hypoxemia, no matter how short. For example, reptiles may survive an initial hypoxemic anesthesia episode, only to die days or weeks later from hypoxic renal damage. High body surface area to volume ratio predisposes small Pets to significant body heat loss during anesthesia. Hypothermia produces prolonged drug metabolism and recovery. Small size makes intubation, venous access and anesthetic monitoring difficult and often requires size-specific or adapted equipment. A high level of skill is imperative to provide the specialized care needed for successful exotic care and anesthesia.
Pre-anesthetic evaluation
Discuss realistic expectations and potential outcomes with client. Provide client education about aftercare and present an accurate treatment plan before the procedure. Include client education about prognosis and anesthetic risk; exotic Pets can respond differently to anesthetic procedures compared to dogs and cats. Due to small body size and related factors, exotic Pets are more prone to anesthetic and surgically related complications. Obtain an accurate body weight, usually in grams. Accurate body weight is imperative to calculate correct drug doses. Obtain a complete history. Determine if the patient can reasonably be handled. Perform as complete a physical exam as possible. Determine if the Pets status is healthy or compromised. Determine "awake" pulse rate, temperature and respiratory rate when possible. Pets that cannot be examined without chemical restraint should be evaluated based on visual observation and history. Handle stressed Pets for as short a period as possible. In some cases, sedation or anesthesia of sick Pets to allow evaluation is preferable to the stress induced by struggling and restraint.
Guidelines for blood sample volumes that can be taken from healthy patients*
(Take smaller amounts from compromised Pets.) Reptiles: Up to 0.5% of body weight. Example: for a 100 gram patient, can take 0.5 ml; for 1000 gram patient, can take 3 to 5 ml Rabbits: Up to 0.5% of body weight, or 3 to 5 ml per 1000 grams of body weight Ferrets: 3 to 5 ml per adult ferret, depending on size Rodents: 1 ml from Pets weighing more than 100 grams, less from smaller Pets Avians: 2 to 3 ml from larger guinea pigs and chinchillas 1 ml per 100 grams body weight
* Adapted from ANTECH Diagnostics sample collection information.
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Reference laboratories can often supply micro-sized blood collection tubes to facilitate send-out diagnostic work-ups for small Pets. Check the comments below each exotic Pet blood test in the current reference lab services directory (each hospital should have one). The reference lab information indicates which collection tubes or containers are best and specifies minimum volume amounts for each test. The most accurate result will be obtained by following these sample container guidelines.
Recommended preoperative fasting and water withholding times for exotic Pets
Species Ferret Fasting Time 4 hrs (dont fast Pets with insulinomas) 30 min 4 hrs 0 24 hrs 46 hrs 46 hrs 812 hrs Water 2 hrs
Rabbit Guinea Pig/ Chinchilla Small Rodents Hedgehogs Reptiles Smaller Avians Larger Psittacines
Pre-anesthetic preparation
Ensure that the proper supplies and equipment are available. The following items will be needed: Non-rebreathing circuit (at 2 to 3 L O2 flow). Warm fluids: 2.5 percent dextrose in 0.45 percent NaCl. Supplemental heat source: heating pad at minimum (with towel layers between Pet and heat source), warm air incubator best if available. Pulse oximeter, ECG, thermometer. Optimal: 24-gauge, 3/4-inch IV catheters or 23 to 20gauge needles or bone marrow needles for IO catheters. Appropriately sized face masks or intubation supplies including: Small face masks. Endotracheal tubes: Large, over-the-needle-catheters/red rubber tubes with homemade gas adaptors. 2.0 mm and larger endotracheal tubes. Specialty endotracheal tubes also exist (<2.0 mm sizes, +/- uncuffed types). Mouth gags (to prevent unexpected tube bitethrough). Laryngoscope or otoscope to facilitate intubation. Lidocaine gel (endotracheal tube lubricant to reduce the risk of laryngospasm). Familiarize yourself with pre-anesthetic fasting recommendations. Some exotic Pets should not be fasted or fasted for only short periods before anesthesia to prevent hypoglycemia.
030 min (mouth should be empty of food and water) 2 hrs 0 2 hrs 01 hrs 02 hrs (want empty crop) 02 hrs (want empty crop)
Allow stressed Pets to calm before anesthesia. Overstimulation and high sympathetic tone can override sedatives and predispose to vasoconstriction, increased myocardial workload and cardiac arrhythmias. Some exotic Pets (particularly rabbits and many birds) may benefit from hospitalization the night before anesthesia to allow acclimatization to the hospital environment and to gather samples for pre-anesthetic testing. This reduces stress in the immediate pre-anesthetic period. Maintenance of correct body temperature is imperative. Warm subcutaneous (SC), intravenous (IV) or intraosseous (IO) fluids should be administered before, during and after anesthesia. Provide supplemental heat as needed, especially during surgery and recoveryuse heating pads, warm air or warm water bottles. Avoid thermal burnsmonitor heat sources closely. Place a dry barrier (towel layers) between Pets and heating pads to reduce potential for burns. Incubators pre- and postsurgically are ideal. Prepare to perform anesthesia in a warm immediate environment. Clip hair cautiously from as small an area as possible and do as much prep as possible prior to induction. Use warmed surgical prep solutions. Substitute warm, diluted chlorhexidine or saline for scrub rinsesavoid alcohol. Cover as much of the Pet as possible during surgery to retain body heat. Use clear, adhesive plastic surgery drapes whenever possible. Use adhesive tape sparingly; the delicate skin of small Pets tears easily. Masking, paper or autoclave tape may be better choices.
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Fluid support is vital to maintain hydration, blood volume and fluid balance. Set an intravenous or intraosseous catheter when possible; IV is preferred. Use a micro-drip fluid administration set. Whenever possible, a fluid pump should be used to ensure accurate delivery rates and volumes. Subcutaneous fluids should be administered if IV/IO access is not available. Be aware that SC fluid therapy may not be adequate to correct pre-existing dehydration in the immediate preoperative period. Stabilize hydration before anesthesia in all possible instances. SC administration of fluids containing 2.5 percent dextrose is appropriate for peri-anesthetic support when IV/IO access is not possible. Avoid the use of SC fluids containing greater than 2.5 percent dextrose or repeated use not related to the peri-anesthetic period. Hypertonic dextrose solutions (such as 5 percent) or repeated administration of dextrose-containing fluids may increase possibility of infection and subsequent tissue necrosis at the administration site.
Species Hamster
Parenteral Access & Injection Sites SC, IM, IO (tibial crest), IV: lateral tarsus, cephalic, lingual, dorsal penile
Comments IV access difficult use 27- to 30-gauge needles IM maximum volume is 0.25 ml, for IO use 22-g spinal needle IM: Use 23-gauge or smaller needles, maximum IM volume 0.3 ml IV: Use 25-gauge or smaller needle IM: Use 23-gauge or smaller needles, maximum IM volume 0.3 ml IV: Use 25-gauge or smaller needle
Chinchilla
SC, IM, IO, IV: femoral, cephalic, lateral saphenous, jugular, auricular, dorsal penile, lateral abdomen, tail
Hedgehog
Small mammals
Suggested reading for parenteral access or injection in small exotic mammals: 1. Adapted from The Veterinary Clinics of North America: Exotic Animal Practice. 2001 Jan;4(1). 2. Quesenberry K., Carpenter J. Ferrets, Rabbits, and Rodents, Clinical Medicine and Surgery, 2nd ed. W.B. Saunders;2004. 3. Longley L. Anaesthesia of Exotic Pets, W.B. Saunders, 2008.
SC, IM, IO (tibial, femoral), IV: jugular, cephalic, lateral saphenous, femoral
Reptiles/Avians
Reptiles: Historically, it has been preferable to administer injections into the cranial half of the body of reptiles to decrease drug passage through the renal portal system. Recent studies indicate it is unlikely that the injection site actually has significant influence on most drug activity. However, the coccygeal vein blood of some lizards does appear to enter the renal portal system. Therefore, renal-toxic drugs or those with a very high first-pass renal excretion rate should not be administered via the coccygeal vein in reptiles.
Suggested reading for vascular access/injection and intramuscular injection in reptiles and avians: 1. Adapted from The Veterinary Clinics of North America: Exotic Animal Practice. 2001 Jan;4(1). 2. Bonagura, JD (ed). Kirks Current Veterinary Therapy XII, Small Animal Practice. W.B. Saunders;1995. 3. BSAVA Manual of Psittacine Birds. British Small Animal Veterinary Association. Iowa State University Press;1996. 4. Longley L. Anaesthesia of Exotic Pets, W.B. Saunders, 2008.
Species Ferret
Parenteral Access & Injection Sites SC, IM, IO, IV: cephalic, jugular, lateral saphenous, lateral tail SC, IM, IO (trochanteric fossa), IV: marginal ear, cephalic, lateral saphenous, jugular
Comments
Blood clots quickly, external jugular is primary drainage for head (swelling occurs if jugular catheter remains in place) Guinea Pig SC, IM, IO (trochantSelf-mutilation can oceric fossa), IV: marginal cur with IM injections, ear, medial saphenous, vascular access often lateral saphenous difficult due to short, proximal to hock, dorsal mobile, friable veins penile, jugular Rat and SC, IM, IO, IV: Lateral tail veins are Mouse jugular, lateral tail difficult to obtain blood from except by capillary action Gerbil SC, IM, IO, IV: lateral Use 25-gauge needles tail, saphenous, metatarsal
Rabbit
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Reptile Type
Snake
Parenteral Access and Injection Sites

IV: jugular (right), coccygeal, heart (reserve for emergencies), palatine (medium to large snakes)
Comments
Right jugular vein is larger than leftincise four to seven scutes cranial to the heart at the junction of the ventral scutes and right lateral body scales. Jugular is identified by blunt dissection just medial to tips of ribs. Coccygeal vein is located on ventral midline of tail. Use 27- to 22-gauge needleinsert 1/3 of distance from cloaca to tail to avoid hemipenes (males) and anal sacs. Aspirate until blood or bone encountered. If unsuccessful, reposition cranially or caudally. Difficult to use in small snakes. Heart (reserve for emergencies) Use 27- to 25-gauge needles in smaller snakes, 22-g in very large snakes. Insert needle at a 45-degree angle to ventricles and aspirate gently. Palatine vein is located medial to palatine teeth in roof of mouth. Take care not to injure fingers. Usually accessed while Pet is under anesthesia or a secure mouth gag is in place.
Reptile Type
Lizard

IV: cephalic, ventral abdominal, jugular, coccygeal IM route: proximal limbs (shoulder to elbow) recommended Not recommended: Distal limb (below elbow) IM/SC injections may cause tissue necrosis.
Comments
Cephalic vein is located on dorsal (anterior) surface of distal forelega cut-down incision from the elbow distal and medial over the dorsal forearm allows visualization of vein. Ventral abdominal vein is located on ventral midline and can be entered percutaneously or following small skin incision on the midline to visualize vessels. Can also be catheterized in some patients. Jugular vein is located on lateral neck, more dorsal than would be expected in mammals. Requires a longitudinal incision and blunt dissection to visualize. Coccygeal vein is located on ventral midline of tail. Insert small gauge needle sufficiently caudal to the cloaca to avoid hemipenes (males) and anal sacs. Vessel is entered directly from ventral midline or laterally. Insert needle ventral to transverse process and advance until vertebral body is contacted. While gently aspirating, walk needle ventrally around vertebral body until vessel is found.
IM route: paravertebral musculature preferred
Turtle and Tortoise
IV: jugular, dorsal coccygeal, brachial, subcarpacial (supravertebral)
Jugular vein is located on lateral surface of neck auricular scale. Some Pets may be percutaneously catheterized; others require a longitudinal incision for visualization. Dorsal coccygeal vein is located in midline of tail, dorsal to vertebrae. Clean injection sites of feces or debris. Insert needle in midline and advance until bone is contacted. Gentle aspiration allows identification of vessel. Subcarpacial (supravertebral) venous sinus: located beneath the carapace on midline just caudal to the last cervical vertebrae and just in front of the first thoracic vertebrae. This is midline on the underside of the carapace, usually just caudal to where the skin meets the carapace. The patients head must be extended or retracted to allow access to the site.
IM route: proximal limbs (shoulder to elbow) recommended
Not recommended: Distal limb (below elbow) IM/SC injections may cause tissue necrosis.
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Reptile Type
Avian

IV: ulnar (basilic, brachial), medial metatarsal (caudal tibial), right jugular
Comments
Ulnar (basilic, brachial) is located near elbow on ventral aspect of wing. Use for birds over 150 grams. Hematoma forms easilyapply pressure for two to three minutes postvenipuncture.
drip set. 2.5 percent dextrose in 0.45 percent NaCl is recommended for routine perioperative fluid administration. IV/IO catheter placed: Begin administration of warm IV/IO fluids at 5 to 10 ml/ kg/hr before induction of anesthesia when possible. Continue fluids until recovery is complete. No IV/IO catheter placed: Begin administration of warm fluids at 5 to 10 ml/kg/ hr SC. Administer 1/4 of the calculated hourly dose every 15 minutes starting before induction of anesthesia, continuing through recovery. Measure fluids, control fluid rates, and monitor patients carefully to prevent fluid overload and pulmonary edema. Maintenance fluid rate: Anesthesia fluid rate: Shock fluid rate: 1.5 to 4.0 ml/kg/hr 5 to 10 ml/kg/hr 30 to 80 ml/kg/hr
IM route: Pectoral Medial metatarsal is located muscles recommended on medial aspect of proximal metatarsus. Jugular (right side) extend neck and part or wet feathers to visualize. This is the easiest vein to access in small birds.
Suggested reading for intraosseous catheterization in reptiles and avians: 1. Adapted from The Veterinary Clinics of North America: Exotic Animal Practice. 2001 Jan;4(1). 2. Bonagura, JD (ed). Kirks Current Veterinary Therapy XII, Small Animal Practice. W.B. Saunders;1995. 3. Harris D. Therapeutic Avian Techniques. Atlantic Coast Veterinary Conference 2002 - Program. 4. Longley L. Anaesthesia of Exotic Pets, W.B. Saunders, 2008.
Pre-oxygenation before induction is recommended (except in some reptiles) if it can be performed without stress. It is performed via an oxygen cage/chamber or induction mask. Supplemental oxygen should be provided from induction through recovery in all patients (except some reptiles). Provide supplemental oxygen even if immobilizing drugs alone are used. It may be necessary to make or obtain special oxygen delivery equipment including tiny masks made from syringe cases with a latex glove diaphragm over the end.
Species
Lizard
Intraosseous Site
Distal femur: Flex stifle. Curve in distal femur usually allows catheter to be introduced proximal to the joint. Proximal tibia: Differentiate from lateral fibula. Pass catheter through tibial crest and advance needle to medial surface of leg as it is passes into the bone. Proximal humerus: Place catheter either into the greater tubercle or slightly medial to it.
Special note for reptiles: Reptiles have unique respiratory physiology. More recent evidence suggests that low oxygen concentrations stimulate reptilian respiration while high oxygen concentrations depress it. Oxygen-rich environments cause respiratory depression in some reptilian species. Pre-induction oxygenation is not routinely recommended in most otherwise healthy reptiles. However, reptiles can suffer from hypoxemia and survive the initial insult only to die days or weeks later from hypoxic renal damage. Therefore, oxygen supplementation is required during induction and anesthesia. Intubation is strongly recommended. Intubation is recommended whenever possible. Reptiles lack a functional muscular diaphragm and will benefit from assisted ventilation [manual or positive pressure ventilation (PPV)] with anesthetic gas and oxygen (via tracheal tube) during anesthesia. This supports adequate tidal volume and oxygen delivery. A PetNurse can provide PPV as needed.
Turtle and Tortoise
Carapace/plastron bridge: Pass needle at an acute angle through the bony bridge between carapace and plastron. This is difficult to do, and catheter usually enters the coelomic cavity rather than the intramedullary space. Distal ulna: Flex carpus. Identify dorsal condyle of distal ulna, insert needle just behind it. Direct needle under dorsal condyle and proximally into ulnar shaft. Proximal tibiatarsus: Identify cranial cnemial crest of proximal tibiatarsus between and just distal to the femoral condyles. Direct needle into the tibial plateau just posterior to cnemial crest and distally into marrow cavity.
Avian
Start fluid administration before anesthesia (IV, IO, SC), IV is preferred. Be sure to use warmed fluids delivered with a micro-
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Due to the need for PPV during anesthesia, reptiles often become hyperoxygenated. Room air (rather than 100 percent oxygen) is recommended during recovery for most reptile species. After anesthetic gas is discontinued, provide one to two minutes of PPV (not to exceed 10 to 12 cm water pressure) with 100 percent oxygen supplementation to allow excretion of anesthetic gas from the lungs. Then disconnect the oxygen and, using room air only, provide occasional PPV breaths until spontaneous respirations are stimulated. Monitor patients carefully. Recovery progresses caudal to cranial. Extubate when movement has begun to occur. Some surgeons are aided by a brace or support that can be placed over small Pets to allow a place for the hands to rest while performing surgery. These can be fashioned from polyvinyl chloride (PVC) pipe cut into various lengths and placed over part of the Pet. Premedication is recommended for all reptiles and small mammals and most avians. It calms, improves handling, reduces the amount of induction and maintenance agents needed, smoothes recovery, reduces vagal effects and may prolong analgesia. Premedication is optimal if it can be performed without causing excess stress. See species specific recommendations noted in the individual anesthetic protocols that follow. Special note: If glycopyrrolate is used as a premedication, Atropine administration for treatment of bradycardia during anesthesia must be adjusted accordingly. Give 1/4 to 1/2 the usual Atropine dose in such cases. When mask anesthetic induction is used, small Pets often hold their breath. In mammals and avians, deep, rapid respiration occurs after breath holding, leading to rapid uptake and anesthetic overdose. Use low induction concentrations of inhalant anesthesiado not exceed 5 percent sevoflurane. Use small masks. Monitor for apnea. Reptiles can be resistant to mask induction, with some species being nearly impossible to induce by mask alone (especially turtles/tortoises and aquatic species).
variable results in avians, making careful manual monitoring imperative. Pulse oximetry probes are useful on ears, tongue, tail, and feet/ toes. Rectal pulse oximetry probes are appropriate for ferrets, rabbits and larger rodents. Rectal probes can be used in the cloacas of some reptiles. Oxygen saturation below 94 percent indicates hypoxia; take immediate steps to correct it. Be aware that pulse oximetry monitors have variable sensitivity in avians. They should be used as an adjunct to manual monitoring and can show trends in oxygenation, but should not be relied upon as a primary monitoring tool in birds. Probes can be placed in the cloaca or on the tongue of some larger avians. ECG leads can be attached directly to the skin, to paper clips placed on skin folds, stainless steel sutures placed in the skin, or small 25-gauge needles placed just into the skin. However, do not waste anesthetic time placing sutures, paper clips, or needles if regular ECG leads will work. If the leads are too tight for delicate skin, loosen them before use. Triangulate the heart for the best reading. Use contact gel rather than alcohol-based contact solutions. Manual monitoring techniques are important in exotic Pets. During anesthesia, pulse rate and character usually decrease by roughly 20 percent compared to awake resting rates. If they fall below this range, reduce the anesthetic concentration being used. Respirations should be slow, regular and stable. Loss of response to a toe pinch indicates a surgical anesthetic plane has been reached. Blink response is not a reliable indictor of anesthetic depth in all exotic Pets. Blink response may be impossible (snakes) or difficult to access in reptiles and very small patients. Rabbits especially may exhibit a variable blink response even at deeper planes of anesthesia. Corneal response varies from species to species. Loss of a previously present corneal response is an indicator of excessive anesthetic depth; anesthetic concentration should be decreased. Monitor respiration carefully. Most exotic patients are extremely sensitive to even brief periods of apnea or hypoxemia. Small airways and endotracheal tubes are prone to obstruction with respiratory secretions. (See Special Note for Reptiles, page 100.) Chest wall and rebreathing bag movement as well as condensation and clearing of the face mask/endotracheal tubing aid in the evaluation of respiratory rate and effort. Increased respiratory effort or abnormal respiratory sounds (squeaking, wheezing, unexpected silence) are indictors of impending airway obstruction. Rabbits, guinea pigs, and chinchillas are especially at risk for respiratory obstruction due to excess salivation during mask delivery of anesthetic gases. Maintenance and measurement of body temperature is imperative. Small Pets can lose as much as 10C in 15 minutes (See Exotic Patient Anesthesia Monitoring Form, page 118).
Anesthetic monitoring
Monitoring should be performed continually through induction, anesthesia and recovery. This includes anesthetic depth, cardiopulmonary status (ECG, blood pressure, pulse oximetry, end-tidal CO2), temperature, and reflexes as much as is allowed by patient size. Routine monitoring methods are useful in larger rabbits, ferrets, guinea pigs, chinchillas, reptiles and avians. Pulse oximetry, ECG, and blood pressure or end-tidal CO2 monitoring can be used in larger patients. However, end tidal CO2 may not be accurate and adds considerable dead space to the breathing circuit if used in Pets under a few kilograms. Pulse oximetry and ECG monitoring can be used on most patients with some equipment modification. However, some monitors cannot read the rapid heart rate of small mammals and pulse oximetry provides
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Anesthetic induction and maintenance

The goal of induction is a smooth transition into unconsciousness and to allow placement of a tracheal tube if possible. Tracheal intubation is optimal. However, it is not routinely recommended in all species due to the difficulty and potential to inflict lifethreatening pharyngeal injury in some species (especially rabbits and rodents). See individual species protocols for induction medications/doses.
from exotic anesthesia specialty manufacturers (such as Cooks Veterinary Products). For very small Pets, 18-gauge IV catheters with the needle stylet removed or red rubber feeding tubes with opened ends and homemade adaptors can sometimes be substituted. Tube tie-ins (gauze strip tape) should be attached to these small tubes before intubation. A small amount of lidocaine gel (endotracheal tube lubricant) should facilitate tube placement. Special note for rabbits: Intubation is optimal. Nasal intubation strongly recommended when unable to perform tracheal intubation. Nasal intubation: Using a 4 to 8 French red rubber catheter, estimate the distance from the nasal opening to the level of the pharynx and mark the tube. After induction, instill two to three drops of lidocaine into one nostril. Direct the lubricated red rubber catheter into the ventral meatus and pass to your premeasured mark. Avoid inserting the tube too deeply; otherwise it will most likely pass into the esophagus rather than the trachea. The catheter can be connected to a small tracheal tube adaptor and then hooked to the existing anesthetic machine tubing. Deliver oxygen and gas anesthetic as you would with a tracheal tube. Higher gas concentrations may be needed as the patient may breathe around the tube. Secure the tube by placing it up over the head and taping to the fur or ear. Maintenance of small mammals is very similar to that of dogs and cats. Protective eye ointment should be used. Body temperature must be maintained during induction, anesthesia and through recovery. Perform anesthesia in a warm immediate environment and keep surgical and anesthetic time to a minimum. Heat is easily lost through exposed extremitiescover them (See Preanesthetic Preparation, page 95). Prevent hypoglycemia. Warm fluids with 2.5 percent dextrose should be given, preferably IV. If this route is not available, fluid can be given IO or SC, but absorption time lags for SC administration. Minimize blood and body fluid losses and provide maintenance and replacement fluids as needed. Avoid hypovolemia by administering fluids at a rate of 5 to 10 ml/kg/h.
Compromised Pets should receive at least 1/4 of their hourly fluid requirement volume BEFORE premedications are given whenever possible. Reptiles: Reptiles should be intubated whenever possible. Assisted ventilation is recommend (via endotracheal tube) in anesthetized reptiles as they are prone to respiratory depression during anesthesia, especially when induced with propofol (See Special Note for Reptiles, page 100). DO NOT exceed 5 percent sevoflurane for mask induction. Provide oxygen at 3 to 4 L/minute initially, then at 2 L/minute for maintenance. Avoid the stress of struggling. Use a sedative dose of ketamine, Midazolam, or Telazol depending on species (see individual protocols). Pre-oxygenation is recommended if it can be performed without stress (except in most reptiles). Rabbits: Intubation is optimal. Nasal intubation strongly recommended when unable to perform tracheal intubation. Minimal injectable volume of Telazol is 0.1 ml. If your patients needed dose will be a smaller volume than 0.1 ml, dilute to at least 0.1 ml total volume in sterile water before injection. Example: Patient needs 5 mg Telazol. Telazol is 100 mg/ml, so 5 mg would be 0.05 ml. Minimal desired volume is 0.1 ml/ dose (ml/100 mg x 5 mg = 0.05 ml). Draw up 0.1 ml of 100 mg/ml Telazol in a TB syringe and 0.1 ml of sterile water in a separate TB syringe. Using a third TB syringe with the capped needle detached and the plunge partially pulled out, add the Telazol and the sterile water into the third TB syringe through the needle attachment opening. Replace the capped needle firmly. Mix well by flicking with your finger multiple times. You now have a diluted Telazol solution of 50 mg/ml (a 1:2 dilution). 5 mg of a 50 mg/ml solution (ml/50 mg x 5 mg) = 0.1 ml per dose. Depress plunger to eject excess air and solution until you have your desired amount, in this case, 0.1 ml. Tracheal tube sizes of 2.0 to 3.0 mm are useful in larger Pets (>2 lbs). Smaller Pets may require specialty tubes available
Postoperative care
Recover exotic Pets in a warm environmentan incubator is ideal. Dry areas of wet hair or skin to decrease conductive heat loss. Maintain support of cardiovascular and pulmonary function and monitor body temperature until Pet is fully recovered. As with dogs and cats, this includes supplemental heat and fluid support until the Pet is able to swallow, sit sternal and is at normal body temperature. Monitor respiratory function carefully, as obstruction can easily occur before the patient is fully awake. For reptiles and avians, it is especially important to minimize orthostatic hypotension by maintaining the Pet in a natural body plane (horizontal and sternal
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for reptiles and mammals, horizontal and lateral for avians) and by performing changes in body position slowly. Mammals (except for chinchillas) and avians may benefit from warm ambient or cage temperatures of 20 to 25C during the first 24 hours post-anesthesia. Keep chinchillas below 24C (optimal: 20 to 22C) as they easily become over heated. Reptiles benefit from slightly higher ambient temperatures (25 to 30C for temperate and aquatic reptiles, 30C for tropical reptiles). Be sure to avoid hyperthermia in all species. Continue fluid support as drinking may be decreased during this period. Continue to provide postoperative analgesia. Monitor and record vitals in the medical record as with dogs and cats.
Inhalant anesthesia via a tracheal tube is the first choice if reasonably possible. In some species, tracheal intubation is difficult (guinea pigs/rabbits) or impractical (very small patients). Multiple attempts at intubation should be avoided as laryngeal edema and subsequent respiratory obstruction can occur. Mask maintenance is appropriate when a tracheal tube (or nasal tube for rabbits) is not in place, but great care must be taken to decrease the risk of respiratory obstruction or possible aspiration of gastrointestinal tract contents. The head and neck of exotic Pets can be slightly raised to reduce the potential for aspiration in susceptible species. Positioning reptiles and small mammals with the head and neck extended, tongue pulled out, and in sternal recumbency will reduce the potential for obstruction. Avians should be placed lateral recumbency as a first choice to prevent body weight from inhibiting normal thoracic movement. Prolonged dorsal recumbency, and to a great extent, ventral recumbency, can reduce avian ventilation. Guinea pigs and rabbits may benefit from having the front half of the body raised slightly to reduce pressure of abdominal organs on the diaphragm. Reptiles can be resistant to mask induction, with some species being nearly impossible to induce by mask alone (especially turtles/tortoises and aquatic species).
References 1. Echols S. Avian Anesthesia, Western Veterinary Association Conference Proceedings; 2004. 2. Hochleitner M. Pet Bird Medicine: Anesthesia and Surgery, World Small Animal Veterinary Association Proceedings; 2003. 3. Quesenberry K, Carpenter J, Stein G. Ferrets, Rabbits, and Rodents, Clinical Medicine and Surgery, 2nd ed., Philadelphia, Pa: W.B. Saunders; 2004. 4. Mader D (ed). Reptile Medicine and Surgery, 2nd ed. Philadelphia, Pa: W.B. Saunders; 2005. 5. Heard D (ed). Veterinary Clinics of North America, Exotic Animal Practice, Analgesia and Anesthesia. 2001 Jan; 4(1). 6. Harris D. Therapeutic Avian Techniques. Atlantic Coast Veterinary Conference, 2002 Program. 7. Meredith A, Redrobe S (eds). BSAVA Manual of Exotic Pets. 4th ed. British Small Animal Veterinary Association; 2002. 8. Harrison G, Harrison L. Clinical Avian Medicine and Surgery, Including Aviculture. Philadelphia, Pa: W.B. Saunders; 1998.
Postoperative pain control

Exotic Pets benefit from analgesics as dogs and cats do. Lethargy, anorexia and self-mutilation may occur if postsurgical pain is not controlled. Rabbits are especially reactive to pain; pain control is strongly recommended. Recovery is improved if analgesia is used for one to two hours postsurgically. Most anesthesiologists recommend pre-emptive analgesia. Analgesia given before the onset of pain or before recovery from anesthesia is thought most effective. The duration of action of butorphanol can vary greatly. Some Pets may need repeat dosing as often as every one to two hours. Monitor all recovering Pets frequently for pain or excess sedation. Analgesic Drug Doses for Exotic Petsgiven SC or IM Pain Management Butorphanol Ferret 0.10.5 mg/kg q 24 hrs IM or SC Rabbit 0.11.0 mg/kg q 24 hrs IM or SC
(Limit to 2 doses to reduce potential for GI motility issues.)
Ketoprofen 1 mg/kg q 24 hrs IM or PO 1 to 3 mg/kg q 24 hrs IM
Mouse, Gerbil, Hamster Guinea Pig, Chinchilla Rat Hedgehog Reptile Avian
2 mg/kg q 24 hrs SC 12 mg/kg q 4 hrs SC 2 mg/kg q 24 hrs SC 0.2 mg/kg q 68 hrs SC 1 mg/kg q 1224 hrs IM 1 mg/kg q 24 hrs IM
5 mg/kg SC or PO q 24 hrs
9. Bonagura J (ed). Kirks Current Veterinary Therapy XII, Small Animal Practice. Philadelphia, Pa: W.B. Saunders, 1995. 10. Thurmon J., Tranquilli WJ, Benson GJ (eds). Lumb & Jones Veterinary Anesthesia. 3rd ed. University of Illinois, UrbanaChampaign; 1996. 11. Beynon PH (ed). BSAVA Manual of Psittacine Birds. British Small Animal Veterinary Association. Iowa State University Press; 1996. 12. Pettifer G (ed). Seminars in Avian and Exotic Pet Medicine. 2005 Oct;14(4). 13. Wilson S. Reptile Anesthesia and Surgery. Atlantic Coast Veterinary Conference; 2002. 14. Innis C. Advances in Anesthesia and Analgesia of Reptiles, Western Veterinary Conference; 2003. 15. Longley L. Anaesthesia of Exotic Pets, W.B. Saunders, 2008.
2 mg/kg IM or SC q 24 hrs 2 mg/kg IM or SC 24 hrs
Note on individual protocols: Each patient should be treated as uniquedifferences between species, breeds, strains and individuals exist. This individuality influences what anesthetic drugs are appropriate, and whether mask, tracheal tube or injectable anesthesia maintenance is best.
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Avian Anesthesia Protocol
Evaluation Medical history Temperament Physical exam Gather & evaluate lab data Determine health status: Healthy or compromised? Determine if IV/IO catheter will be placed Determine if Pet will be intubated (intubation optimal) Fast appropriately Provide client education/communicate expectations Requires intubation, but cant do: Consider referral to skilled exotic practitioner
Fluid support/preparation Place IV/IO catheter, if possible, IV preferred. IV/IO catheter in place: Start warm 2.5% dextrose in 0.45% NaCl at 5-10mL/kg/hr IV/IO, continue through recovery. No catheter in place: Start warm 2.5% dextrose in 0.45 NaCl at 5-10 mL/kg/hr SC, continue through recovery. Give 1/4 calculated hourly dose every 15 minutes. Intubation optimal Is endotracheal tube placement required for successful anesthesia/procedure? Do you expect successful placement of endotracheal tube by second try?
Needs intubation, but cant do
Can intubate or not required
Induction Pre-oxygenate if possible without causing stress. Healthy or compromised: Mask with sevo (24%)/O2 and intubate (optimal) or use face mask. O2 at 34 L/min initially, then 2L/min maintenance. Keep Pet warm and monitor.
Premedication optional Premedicate 30-60 minutes before anesthesia Healthy Pet: Midazolam (rst choice) or diazepam (second choice): 0.20.3 mg/kg IM Butorphanol: 0.41.0 mg/kg IM Compromised Pet: Butorphanol: 0.41.0 mg/kg IM Keep Pet warm and monitor.
Maintenance Mask induction: Administer sevourane (24%) and oxygen via mask or endotracheal tube. O2 at 34 L/min initially, then 2L/min maintenance. Use minimal concentration of sevourane necessary. Keep Pet warm and monitor.
Recovery Continue to provide warm uid support through recovery. Provide pain control: Butorphanol 1.0 mg/kg IM q 24 hrs Ketoprofen 2.0 mg/kg IM or SC 24 hrs Keep Pet warm and monitor.
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AVIAN ANESTHESIA PROTOCOL

(See Anesthetic Considerations for Small Exotic Pets, pages 95 to 103, before proceeding.) Consider all avians as high-risk patients. Keep restraint time to a minimum. Stressful restraint and handling can cause death. Address life-threatening emergencies immediately. Delay further procedures until Pet is stabilized. Avians are particularly susceptible to body heat loss. Use a radiant heat source (heat lamp at safe distance), forced warm air or elevated ambient temperature (incubator). Use caution to avoid burns or over-heating. Intubation is optimal. Positive pressure ventilation may be needed to prevent hypoxia during inhalant anesthesia. Use appropriate mouth gag to prevent tube bite through. Non-cuffed endotracheal tubes are preferred. The tracheal mucosa is fragile and the complete tracheal rings of avians do not allow for significant expansion. Do not exceed 10 cm of water pressure during assisted ventilation. If unable to place endotracheal tube but intubation is required (such as respiratory compromise, surgery that will compromise airway, anesthesia time >30 minutes expected), refer Pet to skilled exotic practitioner. Pulse oximetry has variable usefulness in avians attempt its use to track oxygenation trends, but dont rely on it as heavily as done with mammalian patients. Provide supplemental oxygen throughout induction, anesthesia and recovery. Equipment and supplies: Face mask or intubation supplies (including lidocaine gel), non-rebreathing circuit, IV/IO catheter supplies, 2.5 percent dextrose in 0.45 percent NaCl, supplemental heat source, monitoring equipment. Evaluation: History, physical exam, laboratory data (including uric acid), health status, determination if intubation required, client education. Pre-anesthetic preparation: Fast appropriately (small birds four to six hrs, large birds eight to 12 hrs), withhold water 0 to two hrs, IV/IO catheterization optimal (may need placement after induction), start fluid support at 5 to 10 ml/kg/hr (IV preferred).
Premedication
Use is optional. Generally calms induction/recovery, but may also cause delayed recovery in some cases. Administer 30 to 60 minutes before induction. Healthy Pet: Midazolam (first choice) or diazepam (second choice) 0.2 to 0.3 mg/kg IM and butorphanol 0.4 to 1.0 mg/kg IM. Compromised Pet:
Butorphanol 0.4 to 1.0 mg/kg IM.
Induction
Pre-oxygenate (before induction) if possible without causing stress, then mask with sevoflurane/O2. Intubation is optimal. Maintenance: Deliver sevoflurane/O2 via mask/endotracheal tube to effect, maintain body temperature, monitor, provide fluid support and supplemental oxygen. Recovery: Maintain heat and fluid support. Pain Control: Butorphanol 1.0 mg/kg q 24 hrs IM. Ketoprofen 2.0 mg/kg IM or SC q 24 hrs. Dosages are suggested guidelines onlytailor actual amounts to individual patient needs.
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Reptile Anesthesia Protocol
Evaluation Medical history Temperament Physical exam Gather & evaluate lab data Determine health status: Healthy or compromised? Determine if IV/IO catheter will be placed Determine if Pet will be intubated (intubation optimal) Fast appropriately Provide client education/communicate expectations
Fluid support/preparation Place IV/IO catheter if possible. IV/IO catheter in place: Start warm 2.5% dextrose in 0.45% NaCl at 510 mL/kg/hr IV/IO, continue through recovery. No catheter in place: Start warm 2.5% dextrose in 0.45% NaCl at 510 mL/kg/hr IP or SC, continue through recovery. Give 1/4 calculated hourly dose every 15 minutes. Intubation optimal Is endotracheal tube required for successful anesthesia/procedure? Do you expect successful placement of endotracheal tube upon induction?
Requires intubation, but cant do: Consider referral to skilled exotic practitioner.
Premedicate 3060 minutes before anesthesia Healthy Pet: Diazepam 1 mg/kg IM Butorphanol 1 mg/kg IM Compromised Pet: Midazolam 1 mg/kg IM Keep Pet warm and monitor.
Yes IV catheter
No IV catheter
Induction (IV catheter in place) Healthy or compromised: Propofol 3.05.0 mg/kg IV slowly to effect. Give slowly in small boluses to reduce apnea. Monitor for apnea. Intubation optimal, otherwise use face mask. Reptiles usually need positive pressure ventilation to prevent hypoxia during anesthesia. Keep Pet warm and monitor.
Induction (No catheter in place) Healthy Pet: Attempt mask induction with sevo (24%)/O2 (rst choice) or give ketamine 5-10 mg/kg IM, then mask with sevo (14%)/O2. O2 at 3-4L/minute initially, then 2 L/min for maintenance. Some reptiles can hold their breath for extended periods so mask induction not always an option. Compromised Pet: Mask with sevo (25%)O2 (best choice). If struggling or signicantly holding breath, give 5 mg/kg ketamine IM, then mask with sevo (14%)/O2 if needed. O2 at 34L/min initially, then 2 L/minute for maintenance. Ketamine can cause prolonged recovery times in debilitated reptiles. Some reptiles can hold their breath for extended periods; mask induction not always an option. Intubation optimal, otherwise use face mask. Many reptiles need positive pressure ventilation to prevent hypoxia during anesthesia. Keep Pet warm and monitor.
Maintenance Propofol/mask induction: Administer sevourane (24%) and oxygen via mask or endotracheal tube. Use minimal concentration of sevourane necessary. If intubated, ventilate at 26 bpm and dont exceed 1012 cm water pressure. Ketamine induction: Provide supplemental O2 via mask or endotracheal tube. Add sevourane at 14% as needed to maintain desired anesthetic plane. Use minimal concentration of sevourane necessary. If intubated, ventilate at 26 bpm and dont exceed 10-12 cm water pressure. Keep Pet warm & monitor.
Recovery Continue to provide warm uid support through recovery. Provide pain control: Ketoprofen 2.0 mg/kg IM (best) or SC q 24 hrs Butorphanol 1.0 mg/kg IM (best) or SC 1224 hrs Keep Pet warm and monitor.
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REPTILE ANESTHESIA PROTOCOL

(See Anesthetic Considerations for Small Exotic Pets, pages 95 to 103, before proceeding.) Intubation is optimal. Positive pressure ventilation (PPV) is usually needed to prevent hypoxemia during inhalant anesthesia and when propofol is used in most species. For intubation, use non-cuffed tubes, ventilate at 2 to 6 bpm (with no more than 1 to 2 second inspiration time) and dont exceed 10 to 12 cm of water pressure. May survive an initial hypoxemic anesthesia episode, only to die days/weeks later from hypoxic renal damage provide proper oxygenation by performing PPV whenever possible. If unable to place endotracheal tube but intubation required (such as respiratory compromise, surgery that will compromise airway, anesthesia time >30 minutes expected), refer Pet to skilled exotic practitioner. Reptile respiration is stimulated by low oxygen concentrations. Supplemental oxygenation before induction and during postoperative recovery may not be neededroom air can speed recovery in some cases. Do provide supplemental oxygen during induction and anesthesia. Peri-operative fasting is recommended to reduce visceral volume (improves tidal volume) and because digestion is impaired during anesthesia and recovery. IV or IO fluid administration best, intraperitoneal (IP) second best and SC is better than none. SC administration may not be adequate for correction of dehydration or blood loss in the peri-anesthetic period. Debilitated, dehydrated or chilled reptiles have prolonged absorption times for fluids given SC. Optimal temperatures: temperate and aquatic reptiles, 25 to 30C; tropical reptiles, 30C. Equipment and supplies: Face mask or intubation supplies (including lidocaine gel), non-rebreathing circuit, IV/IO cath supplies, 2.5 percent dextrose in 0.45 percent NaCl, supplemental heat, monitoring equipment. Evaluation: History, physical exam, laboratory data, health status, determination if intubation required, client education. Pre-anesthetic preparation: Fast four to six hours, withhold water 0 to 1 hr, IV/IO catheterization optimal, start fluid support at 5 to 10 ml/kg/hr (IV preferred).
Premedication: 30 to 60 minutes before induction

Healthy Pet: Diazepam 1 mg/kg IM and butorphanol 1 mg/kg IM. Compromised Pet: Midazolam 1 mg/kg IM.
Induction:
Healthy Pet:
Propofol IV 3.0 to 5.0 mg/kg IV to effect. Give slowly in small boluses to reduce apnea. If no IV catheter, attempt mask induction with sevoflurane/O2 or give ketamine 5 to 10 mg/kg IM wait for effect, then mask with sevoflurane/O2 to effect. Some reptiles (especially turtles/tortoises) can hold their breath for extended periods, so mask induction is not always an option. Compromised Pet: Propofol IV 3.0 to 5.0 mg/kg IV, to effect. Give slowly in small boluses to reduce apnea. If no IV catheter, attempt mask induction with sevoflurane/O2 (best choice). If struggling or significantly holding breath, give 5 to 10 mg/kg ketamine IM, wait for effect, then mask with sevoflurane/ O2 to effect. Ketamine can cause prolonged recovery times in debilitated reptiles. Some reptiles (especially turtles/ tortoises) can hold their breath for extended periods, so mask induction is not always an option. Maintenance: Intubate if appropriate, sevoflurane/O2 via mask/ endotracheal tube to effect, maintain body temperature, monitor, give fluid support and provide supplemental oxygen during induction and anesthesia. Recovery: Maintain heat and fluid support. Pain Control: Ketoprofen 2.0 mg/kg IM (best route) or SC q 24 hrs. Butorphanol 1.0 mg/kg IM (best route) or SC q 12 to 24 hrs. Dosages are suggested guidelines onlytailor actual amounts to individual patient needs.
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Ferret Anesthesia Protocol
Evaluation: Medical history Temperament Physical exam Gather & evaluate lab data Determine health status: Healthy or compromised? Determine if IV/IO catheter will be placed Determine if Pet will be intubated (intubation optimal) Fast appropriately Provide client education/communicate expectations
Fluid support/preparation Place IV/IO catheter if possible; IV preferred IV/IO catheter in place: Start warm 2.5% dextrose in 0.45% NaCl at 510 mL/kg/hr IV/IO, continue through recovery. No catheter in place: Start warm 2.5% dextrose in 0.45% NaCl at 510 mL/kg/hr SC, continue through recovery. Give 1/4 calculated hourly dose every 15 minutes. Intubation optimal and should be attempted in adults and large juveniles. Is endotracheal tube required for successful anesthesia/procedure? Do you expect successful placement of endotracheal tube by second try?
Requires intubation, but cant do: Consider referral to skilled exotic practitioner.
Premedicate 3060 minutes before anesthesia: Healthy Pet: Acepromazine 0.1 mg/kg IM Butorphanol 0.2 mg/kg IM Glycopyrrolate 0.01 mg/kg IM Compromised Pet: Midazolam (rst choice) or diazepam 0.1 mg/kg IM Butorphanol 0.10.2 mg/kg IM Glycopyrrolate 0.01 mg/kg IM Keep Pet warm and monitor.
Yes IV catheter
No IV catheter
Induction (IV catheter in place) Healthy or compromised: Propofol 2.06.0 mg/kg IV to effect. Intubation optimal, otherwise use face mask. Keep Pet warm and monitor.
Induction (No catheter in place) Healthy Pet: Telazol 6 mg/kg IM, then mask w/ sevourane (1-4%)/O2 if needed. O2 at 34 L/min initially, then 2L/min maintenance. If initial Telazol dose has no effect after 20 minutes, can repeat 1/4-1/2 dose of Telazol once. Compromised: Mask w/sevo (24%)/O2. O2 at 34 L/min initially, then 2L/min maintenance. If struggling, give sedative dose of midazolam 0.5 mg/kg (rst choice) IM or Telazol 1.0 mg/kg IM, wait 20 min, repeat mask attempt. Repeat Telazol at 1.0 mg/kg dose once if needed. Intubation optimal, otherwise use face mask. Keep Pet warm and monitor.
Maintenance Propofol/mask induction: Administer sevourane (24%) and oxygen via mask or endotracheal tube. O2 at 34L/min initially, then 2 L/ min for maintenance. Use minimal concentration of sevourane necessary. Telazol induction: Provide supplemental O2 via mask or endotracheal tube at 34 L/min initially, then 2 L/min for maintenance. Add sevourane at 14% as needed to maintain desired anesthetic plane. Use minimal concentration of sevourane necessary. Keep Pet warm and monitor.
Recovery Continue to provide warm uid support through recovery. Provide pain control: Butorphanol 0.10.5 mg/kg IM or SC q 24 hrs Ketoprofen 1.0 mg/kg IM or PO SID max 5 days Keep Pet warm and monitor.
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FERRET ANESTHESIA PROTOCOL

(See Anesthetic Considerations for Small Exotic Pets, pages 95 to 103, before proceeding.) Use gauze strips to hold the mouth open, allowing visualization of the larynx. Tracheal intubation is optimal and should be attempted in adult and large juvenile ferrets with a 2.0 to 3.0 mm endotracheal tube. Do not try more than twice. Repeated attempts will cause significant laryngeal edema. If unable to place endotracheal tube but intubation required (such as respiratory compromise, surgery that will compromise airway, anesthesia time >30 minutes expected), refer Pet to skilled exotic practitioner. Palpebral reflexes may be lost at a surgical anesthetic plane. Underlying potential disease states to consider include adrenal tumors, cardiomyopathy, anemia, hypoglycemia and endocrinopathies. Provide supplemental oxygen throughout induction, anesthesia, and recovery. Equipment and supplies: Face mask or intubation supplies (including lidocaine gel), non-rebreathing circuit, IV/IO catheter supplies, 2.5 percent dextrose in 0.45 percent NaCl, supplemental heat source, monitoring equipment. Evaluation: History, physical exam, laboratory data, health status, determination if intubation required, client education. Pre-anesthetic preparation: Fast most Pets four hours (dont fast Pets with insulinomas), withhold water two hours, IV/IO catheterization optimal (may need to be placed after premed or induction), start fluid at 5 to 10 ml/kg/hr (IV best).
Induction: Pre-oxygenate (before induction) if possible

without causing stress, then: Healthy Pet with IV catheter: Propofol 2.0 to 6.0 mg/kg IV to effect. Healthy Pet without IV catheter: Telazol 6 mg/kg IM, wait for effect and mask with sevoflurane/O2 if needed. If initial Telazol dose has no effect after 20 minutes, can repeat 1/4 to 1/2 dose of Telazol once.
Compromised Pet with IV catheter: Propofol 2.0 to 6.0 mg/kg IV to effect. Compromised Pet without IV catheter: Mask with sevoflurane/O2 to effect. If struggling, give sedative dose of midazolam at 0.5 mg/kg (first choice) or Telazol (second choice) 1.0 mg/kg IM, wait 20 minutes and mask again. Repeat Telazol at 1.0 mg/kg dose once if needed. Maintenance: O2 /sevoflurane via mask/endotracheal tube to effect, maintain body temperature, monitor, provide fluid support and supplemental oxygen. Recovery: maintain heat and fluid support. Pain control: Butorphanol 0.1 to 0.5 mg/kg q 2 to 4 hrs IM or SC. Ketoprofen 1.0 mg/kg IM or PO SID for no longer than five days total. Dosages are suggested guidelines onlytailor actual amounts to individual patient needs.

Healthy Pet: Acepromazine 0.1 mg/kg IM and butorphanol 0.2 mg/kg IM and glycopyrrolate 0.01 mg/kg IM. Compromised Pet: Midazolam (first choice) OR diazepam (second choice) 0.1 mg/kg IM and butorphanol 0.1 to 0.2 mg/kg IM and glycopyrrolate 0.01 mg/kg IM.
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Rabbit Anesthesia Protocol
Evaluation Medical history Temperament Physical exam Gather & evaluate lab data Determine health status: Healthy or compromised? Determine if IV/IO catheter will be placed Intubation optimal (tracheal or nasal) Fast appropriately Provide client education/communicate expectations
Fluid support/preparation Place IV/IO catheter if possible (IV preferred) IV/IO catheter in place: Start warm 2.5% dextrose in 0.45% NaCl at 510 mL/kg/hr IV/IO, continue through recovery. No catheter in place: Start warm 2.5% dextrose in 0.45% NaCl at 510 mL/kg/hr SC, continue through recovery. Give 1/4 calculated hourly dose every 15 minutes. Intubation optimal. If unable to easily perform tracheal intubation (which can be difcult), nasal intubation strongly recommended. Exception: Pre-existing airway compromise or procedures that require tracheal intubation to protect airway may need referral to a skilled exotic practitioner. Tracheal intubation required for successful anesthesia/procedure?
Requires tracheal intubation: Consider referral to skilled exotic practitioner.
Needs tracheal intubation
Tracheal intubation not required (use nasal)
Premedicate 3060 minutes before anesthesia Healthy Pet: Diazepam 0.20.5 mg/kg IM (separate syringe) Butorphanol 0.2 mg/kg IM Glycopyrrolate 0.010.1 mg/kg IM Compromised Pet: Diazepam 0.2 mg/kg IM (separate syringe) Butorphanol 0.2 mg/kg IM Glycopyrrolate 0.01 - 0.1 mg/kg IM Keep Pet warm and monitor.
Induction: Pre-oxygenate if possible without causing stress. Healthy: Ketamine 1020 mg/kg IM, wait 20 min, perform nasal intubation. Deliver sevourane (14%)/O2 via tube as needed. O2 at 34 L/min initially, then 2L/min maintenance. If unable to perform nasal intubation, can maintain via face mask w/ sevo (24%)/O2. O2 at 34 L/min initially, then 2L/min maintenance, but intubation preferred. Compromised: Mask w/sevo (2-4%)/O2 to effect, perform nasal intubation. Deliver sevourane (14%)/O2 via tube as needed. O2 at 34 L/min initially, then 2L/min maintenance. If unable to perform nasal intubation, can maintain via face mask w/ sevo (24%)/O2. O2 at 34 L/min initially, then 2L/min maintenance, but intubation preferred. If struggling give ketamine 10 mg/kg IM, wait 20 min, perform nasal intubation and sevo/O2 delivery as above. Keep Pet warm and monitor.
Maintenance Mask induction: Administer sevourane (24%) and oxygen via nasal tube or face mask if no tube. O2 at 34L/min initially, then 2 L/min for maintenance. Use minimal concentration of sevourane necessary. Ketamine induction: Provide supplemental O2 via nasal tube or face mask if no tube at 34 L/min initially, then 2 L/min for maintenance. Add sevourane at 14% as needed to maintain desired anesthetic plane. Use minimal concentration of sevourane necessary. Keep Pet warm and monitor.
Recovery Continue to provide warm uid support through recovery. Provide pain control: Butorphanol 0.11.0 mg/kg IM or SC q 24 hrs* Ketoprofen 3.0 mg/kg IM q 24 hrs * Limit to two doses to reduce potential for GI motility issues. Keep Pet warm and monitor.
PAGE 110
RABBIT ANESTHESIA PROTOCOL

(See Anesthetic Considerations for Small Exotic Pets, pages 95 to 103, before proceeding.) Difficult to anesthetize as they are easily stressed and can injure themselves, often have underlying lung disease, are prone to respiratory depression, can be difficult to intubate, may have significant anorexia postsurgically, and have great variability in drug response between breeds and individuals. Excess salivation is common and can lead to respiratory obstruction. Monitor respiration carefully. Intubation is optimal. Great care must be usedrepeated attempts at tracheal intubation can cause significant laryngeal edema. Nasal intubation strongly recommended when unable to perform tracheal intubation. If tracheal intubation required (such as respiratory compromise, surgery that will compromise airway, anesthesia time >20 minutes expected), but attempt is unsuccessful, refer Pet to skilled exotic practitioner. Palpebral reflex is highly variable. Do not rely on it as an indicator of anesthetic depth. Ear pinch reflex is lost at a surgical plane of anesthesia. Particularly vulnerable to corneal damage from drying or mechanical trauma during anesthesia. Lubricate eyes well. Use adequate padding or place donut pads around eyes to prevent trauma. Provide oxygen throughout induction, anesthesia and recovery. Pulse oximetry is critical during maintenance to monitor for hypoxemia. Equipment and supplies: Face mask and intubation supplies (including lidocaine gel), non-rebreathing circuit, 2.5 percent dextrose in 0.45 percent NaCl, IV/IO catheterization supplies, supplemental heat source, monitoring equipment. Evaluation: History, physical exam, laboratory data, health status, determination if intubation required, client education. Pre-anesthetic preparation: Fast and withhold water 30 minutes (be sure mouth is clear of food/liquid before induction), IV/IO catheterization optimal (may need to be placed after premed or induction), start fluid 5 to 10 mL/kg/hr (IV best).
Premedication:
Healthy Pet:
30 to 60 minutes before induction
Diazepam 0.2 to 0.5 mg/kg IM (in separate syringe) and butorphanol 0.2 mg/kg IM and glycopyrrolate 0.01 to 0.1 mg/kg IM. Compromised Pet: Diazepam 0.2 mg/kg IM (in separate syringe) and butorphanol 0.2 mg/kg IM and glycopyrrolate 0.01 to 0.1mg/ kg IM.
Induction: pre-oxygenate (before induction) if possible

without causing stress, then: Healthy Pet: Ketamine 10 to 20 mg/kg IM, wait 20 minutes, perform nasal intubation, then sevoflurane/O2 to effect if needed. Compromised Pet: Mask with sevoflurane/O2 to effect, perform nasal intubation. If struggling, give ketamine 10 mg/kg IM, wait 20 minutes, perform nasal intubation, then sevoflurane/O2 to effect if needed. Maintenance: O2 /sevoflurane via mask/endotracheal tube to effect, maintain body temperature, monitor, provide fluid support and supplemental oxygen. Recovery: Maintain heat and fluid support. Pain control: Butorphanol 0.1 to 1.0 mg/kg q two to four hrs IM or SC.* Ketoprofen 3.0 mg/kg q 24 hrs IM. * Limit to two doses to reduce potential for GI motility issues. Dosages are suggested guidelines onlytailor actual amounts to individual patient needs.
PAGE 111
Guinea Pig and Chinchilla Anesthesia Protocol
Evaluation Medical history Temperament Physical exam Gather & evaluate lab data Determine health status: Healthy or compromised? Intubation not routinely recommended & IV catheter attempted only once due to small body size. Can try IO catheter as well. Fast appropriately Provide client education/communicate expectations
Fluid support/preparation: Start warm 2.5% dextrose in 0.45% NaCl at 510 ml/kg/hr SC, continue through recovery. Give 1/4 calculated hourly dose q 15 min. Attempt 24 g IV catheter once. Can also attempt IO catheter. Intubation not routinely recommended. Exception: pre-existing airway compromise or procedures that require intubation to protect airway may need referral to a skilled exotic practitioner. Is endotracheal tube required for successful anesthesia/procedure? Endotracheal tube placement is difcult in guinea pigs and chinchillas.
Requires intubation Consider referral to skilled exotic practitioner.
Needs intubation
Intubation not required
Premedicate 30-60 minutes before anesthesia Healthy Pet: Acepromazine Butorphanol Atropine Compromised: Diazepam Butorphanol Atropine Guinea Pig: 0.1 mg/kg SC 0.1 mg/kg SC 0.05 mg/kg SC Guinea Pig: 1 mg/kg SC 0.1 mg/kg SC 0.05 mg/kg SC Chinchilla: 0.05 mg/kg SC 0.1 mg/kg SC 0.05 mg/kg SC Chinchilla: 1 mg/kg SC 0.1 mg/kg SC 0.05 mg/kg SC
Keep Pet warm and monitor.
Induction: Pre-oxygenate if possible without causing stress. Healthy: Telazol 5 mg/kg SC, then mask w/sevourane (1-4%)/O2 if needed. O2 at 34L/min initially, then 2L/min maintenance. If initial Telazol dose has no effect after 20 minutes, can repeat 1/41/2 dose of Telazol once. Compromised: Mask w/sevo (24%)/O2. O2 at 34L/min initially, then 2L/min maintenance. If struggling can give Telazol 1.0 mg/kg SC, wait 20 min, repeat mask attempt. Repeat Telazol at 1.0 mg/kg dose once if needed. Keep Pet warm and monitor.
Recovery Continue to provide warm uid support through recovery. Provide pain control: Butorphanol 1.02.0 mg/kg SC q 4 hrs Keep Pet warm and monitor.
Maintenance Mask Induction: Administer sevo (2-4%) & O2 via face mask. O2 at 3-4L/minute initially, then 2L/min for maintenance. Use minimal concentration of sevo necessary. Telazol Induction: Provide supplemental O2 via face mask at 3-4L/min initially, then 2 L for maintenance. Add sevo at 1-4% as needed to maintain desired anesthetic plane. Use minimal concentration of sevo necessary. Keep Pet warm and monitor.
PAGE 112
GUINEA PIG AND CHINCHILLA ANESTHESIA PROTOCOL

(See Anesthetic Considerations for Small Exotic Pets, pages 95 to 103, before proceeding.) Potential for anesthetic complication is high as these Pets stress easily, are difficult to intubate, are prone to postoperative complications, and have differing drug responses per individual. Intubation not recommended unless surgical procedures may compromise the airway or Pet is significantly compromised. Often need to clean out mouth prior to induction; have tendency to retain food in oral cavity. Attempt IV catheterization in larger Pets once. Use 24 g IV catheter in cephalic vein. If intubation required (such as respiratory compromise, surgery that will compromise airway, anesthesia time >30 minutes expected) refer Pet to skilled exotic practitioner. Anticholinergics are generally used (even for brief immobilization) since large amounts of thick respiratory secretions are often produced and can lead to respiratory obstruction. Ear pinch and pedal withdrawal reflexes are lost at a surgical plane of anesthesia. Provide oxygen throughout induction, anesthesia, and recovery. Equipment and supplies: Face mask or intubation supplies (including lidocaine gel), non-rebreathing circuit, 2.5 percent dextrose in 0.45 percent NaCl, supplemental heat source, monitoring equipment. Evaluation: History, physical exam, laboratory data, health status, determination if intubation required, client education. Pre-anesthetic prep: Fast four hours and withhold water two hours, start fluid at 5 to 10 mL/kg/hr (SC). Be sure mouth is clear of food/fluid before induction.
Premedication:
30 to 60 minutes before induction; in healthy Pets, can be diluted in first dose of SC fluids. If giving diazepam separately from SC fluids, IM route is first choice if can be used without causing patient trauma; otherwise, give SC. Healthy Pet: Acepromazine Butorphanol Atropine Compromised Pet: Diazepam Butorphanol Atropine Guinea Pig: 0.1 mg/kg SC 0.1 mg/kg SC 0.05 mg/kg SC Guinea Pig: 1.0 mg/kg IM/SC 0.1 mg/kg SC 0.05 mg/kg SC Chinchilla: 0.05 mg/kg SC 0.1 mg/kg SC 0.05 mg/kg SC Chinchilla: 1.0 mg/kg IM/SC 0.1 mg/kg SC 0.05 mg/kg SC
Induction: Pre-oxygenate (before induction) if possible without causing stress, then: Healthy Pet: Telazol 5 mg/kg SC, wait for effect, then mask with sevoflurane/O if needed. If initial Telazol dose has no effect after 20 minutes, can repeat to dose of Telazol once.
2
Compromised Pet: Mask with sevoflurane/O2 to effect. If struggling, give sedative Telazol dose 1.0 mg/kg SC, wait 20 minutes and mask again. Repeat Telazol at 1.0 mg/kg dose once if needed. Maintenance: O2/sevoflurane via mask to effect, maintain body temperature, monitor, provide fluid support and supplemental oxygen. Recovery: Maintain heat and fluid support. Pain control: Butorphanol 1 to 2 mg/kg q four hrs SC. Dosages are suggested guidelines onlytailor actual amounts to individual patient needs.
PAGE 113
Rat, Mouse, Gerbil and Hamster Anesthesia Protocol
Evaluation: Medical history Temperament Physical exam Gather & evaluate lab data Determine health status: Healthy or compromised? Intubation & IV/IO catheterization not routinely recommended due to small body size. Do not fast or withhold water. Client education/communicate expectations
Fluid support/preparation Start warm 2.5% dextrose in 0.45% NaCl at 510 mL/kg/hr SC, continue through recovery. Give 1/4 calculated hourly dose q 15 min. Intubation & IV/IO catheterization not routinely recommended. Exception: Pre-existing airway compromise or procedures that require intubation to protect airway may need referral to a skilled exotic practitioner. Is endotracheal tube required for successful anesthesia/procedure?
Requires intubation: Consider referral to skilled exotic practitioner.
Needs intubation
Premedicate 30-60 minutes before anesthesia (doses given SC) Healthy Pet: Acepromazine Butorphanol Diazepam or Midazolam Atropine Hamster 1 mg/kg 1 mg/kg ---------- 0.05 mg/kg Rat 1 mg/kg 1 mg/kg ---------- 0.05 mg/kg Rat 1 mg/kg 1 mg/kg 0.05 mg/kg Mouse 1 mg/kg 1 mg/kg ---------- 0.05 mg/kg Mouse 1 mg/kg 1 mg/kg 0.05 mg/kg Gerbil NO 1 mg/kg 1 mg/kg 0.05 mg/kg Gerbil 1 mg/kg 1 mg/kg 0.05 mg/kg
Compromised Pet: Hamster Butorphanol 1 mg/kg Diazepam or 1 mg/kg Midazolam Atropine 0.05 mg/kg Keep Pet warm and monitor.
Induction: Pre-oxygenate if possible without causing stress. Healthy: Telazol 5 mg/kg IM, then mask w/sevo (14%)/O2 if needed. O2 at 34 L/min initially, then 2L/min maintenance. If initial Telazol dose has no effect after 20 minutes, can repeat 1/41/2 dose of Telazol once. Compromised: Mask w/sevo (24%)/O2. O2 at 3-4L/min initially, then 2L/min maintenance. If struggling, can give Telazol 1.0 mg/kg SC, wait 20 min, repeat mask attempt. Repeat Telazol at 1.0 mg/kg dose once if needed. Keep Pet warm and monitor.
Maintenance Mask induction: Administer sevourane (24%) and oxygen via face mask. O2 at 34 L/minute initially, then 2L/min for maintenance. Use minimal concentration of sevourane necessary. Telazol induction: Provide supplemental O2 via face mask at 34 L/minute initially, then 2 L/min for maintenance. Add sevourane at 1-4% as needed to maintain desired anesthetic plane. Use minimal concentration of sevourane necessary. Keep Pet warm and monitor.
Recovery Continue to provide warm uid support through recovery. Provide pain control: Mouse, Gerbil, Hamster: Butorphanol 2 mg/kg SC q 24 hrs Rat: Butorphanol 2 mg/kg SC q 24 hrs, ketoprofen 5 mg/kg SC/PO q 24 hrs Keep Pet warm and monitor.
PAGE 114
RAT, MOUSE, GERBIL AND HAMSTER ANESTHESIA PROTOCOL

(See Anesthetic Considerations for Small Exotic Pets, pages 95 to 103, before proceeding.) Intubation not recommended unless surgical procedures may compromise airway or Pet is significantly compromised. IV catheter insertion not routinely recommended. If intubation required (such as respiratory compromise, surgery that will compromise airway, anesthesia time >30 minutes expected) refer Pet to skilled exotic practitioner. Provide supplemental oxygen throughout induction, anesthesia and recovery. Tail and ear pinch, as well as pedal withdrawal reflexes disappear at a surgical anesthetic plane. Common diseases include respiratory infections (subclinical disease is common) and chronic otitis media. Equipment and supplies: Face mask or intubation supplies (including lidocaine gel), non-rebreathing circuit, 2.5 percent dextrose in 0.45 percent NaCl, supplemental heat source, monitoring equipment. Evaluation: History, physical exam, laboratory data, health status, determination if intubation required, client education. Pre-anesthetic prep: DO NOT fast or withhold water, start fluid at 5 to 10 ml/kg/hr (SC).
Induction: Pre-oxygenate (before induction)

without stress if possible, then: Healthy Pet: Telazol 5 mg/kg SC, wait for effect, then mask with sevoflurane/O2 if needed. If initial Telazol dose has no effect after 20 minutes, can repeat 1/4 to 1/2 dose of Telazol once SC. Compromised Pet: Mask with sevoflurane/O2. If struggling, give sedative Telazol dose 1.0 mg/kg SC, wait 20 minutes and mask again. Repeat Telazol dose at 1.0 mg/kg once if needed. Maintenance: Sevoflurane/O2 via mask to effect, maintain body temperature, monitor, provide fluid support and supplemental oxygen. Recovery: Maintain heat and fluid support. Pain control: Mouse, gerbil, hamster: Butorphanol 2.0 mg/kg q two to four hrs SC. Rat: Butorphanol 2.0 mg/kg q two to four hrs SC, Ketoprofen 5 mg/kg SC/PO q 24 hrs
Dosages are suggested guidelines onlytailor actual amounts to individual patient needs.
Premedication: 30 to 60 minutes before induction; in healthy Pets, can be diluted in first dose of SC fluids. If giving diazepam/midazolam separately from SC fluids, IM route is first choice if can be used without causing patient trauma; otherwise, give SC.
Healthy Pet: Acepromazine Butorphanol Diazepam or midazolam Atropine 0.05 mg/kg SC Rat 1 mg/kg SC 1 mg/kg IM/SC 0.05 mg/kg SC 0.05 mg/kg SC Mouse 1 mg/kg SC 1 mg/kg IM/SC 0.05mg/kg SC Rat 1 mg/kg SC 1 mg/kg SC Mouse 1 mg/kg SC 1 mg/kg SC Gerbil Do Not Use 1 mg/kg SC 1 mg/kg IM/SC 0.05 mg/ kg SC Gerbil 1 mg/kg SC 1 mg/kg IM/SC 0.05 mg/ kg SC 0.05 mg/kg SC Hamster 1 mg/kg SC 1 mg/kg IM/SC 0.05 mg/kg SC Hamster 1 mg/kg SC 1 mg/kg SC
Compromised Pet: Butorphanol Diazepam or midazolam Atropine
PAGE 115
Hedgehog Anesthesia Protocol
Evaluation: Medical history Temperament Physical exam Gather & evaluate lab data Determine health status: Healthy or compromised? Intubation & IV/IO catheter not routinely recommended due to small body size. Fast appropriately Provide client education/communicate expectations
Fluid support/preparation: Start warm 2.5% dextrose in 0.45% NaCl at 510 mL/kg/hr SC, continue through recovery. Give 1/4 calculated hourly dose every 15 minutes. Intubation & IV/IO catheter not routinely recommended. Exception: Pre-existing airway compromise or procedures that require intubation to protect airway may need referral to a skilled exotic practitioner. Is endotracheal tube required for successful anesthesia/procedure? Extra care and specialized tubes are usually required in Hedgehogs.
Requires intubation: Consider referral to skilled exotic practitioner.
Needs intubation
Premedicate 3060 minutes before anesthesia Healthy or compromised Pet: Butorphanol 0.1 mg/kg IM or SC under furred skin Keep Pet warm and monitor.
Induction: Pre-oxygenate if possible without causing stress. Healthy: Telazol 1 mg/kg SC. Wait for effect, then mask w/sevourane (14%)/O2 if needed. O2 at 34 L/min initially, then 2 L/min maintenance. If initial Telazol dose has no effect after 20 minutes, can repeat 1/41/2 dose of Telazol once SC. Compromised: Mask w/sevo (24%)/O2. O2 at 34 L/min initially, then 2 L/ min maintenance. If signicant struggling, give sedative Telazol dose 1 mg/ kg SC, wait 20 min, then mask again. If initial Telazol dose has no effect after 20 minutes, can repeat 1/41/2 dose of Telazol once SC. Keep Pet warm and monitor.
Maintenance Mask induction: Administer sevourane (24%) & oxygen via face mask (or endotracheal tube if intubated). O2 at 34 L/minute initially, then 2 L/min for maintenance. Use minimal concentration of sevourane necessary. Telazol induction: Provide supplemental O2 via face mask (or endotracheal tube) at 34 L/minute initially, then 2 L/min for maintenance. Add sevourane at 14% as needed to maintain desired anesthetic plane. Use minimal concentration of sevourane necessary. Keep Pet warm and monitor.
Recovery Continue to provide warm uid support through recovery. Provide pain control: Butorphanol 0.2 mg/kg SC q 68 hrs Keep Pet warm and monitor.
PAGE 116
HEDGEHOG ANESTHESIA PROTOCOL

(See Anesthetic Considerations for Small Exotic Pets, pages 95 to 103, before proceeding.) Intubation not recommend unless surgical procedures may compromise the airway or Pet is significantly compromised. IV catheter insertion not routinely recommended. If intubation required (such as respiratory compromise, surgery that will compromise airway, anesthesia time >30 minutes expected), refer Pet to skilled exotic practitioner. Provide supplemental oxygen throughout induction, anesthesia, and recovery. Common health problems include oral disease (including masses that can compromise respiration), dilated cardiomyopathy, hepatic lipidosis, obesity, and various types of neoplasia. Provide supplemental oxygen throughout induction, anesthesia, and recovery. Equipment and supplies: Face mask or intubation supplies (including lidocaine gel), non-rebreathing circuit, 2.5 percent dextrose in 0.45 percent NaCl, supplemental heat source, monitoring equipment. Evaluation: History, physical exam, health status, determination if intubation required, client education. Pre-anesthetic preparation: Fast most Pets two to four hours, withhold water two hours, start fluid at 5 to 10 ml/kg/hr SC under furred skin. Skin under areas with spines can have very slow absorption.

Healthy or compromised Pet: Butorphanol 0.1 mg/kg IM best if can be given without causing patient trauma, otherwise SC under furred skin.
Induction: Pre-oxygenate (before induction) without

stress if possible, then: Healthy Pet: Telazol 1 mg/kg SC, wait for effect, then mask with sevoflurane/O2 if needed. If initial Telazol dose has no effect after 20 minutes, can repeat 1/4 to 1/2 dose of Telazol once SC. Compromised Pet: Mask with sevoflurane/O2. If significant struggling, give sedative Telazol dose 1 mg/kg SC, wait 20 minutes and mask again. If initial Telazol dose has no effect after 20 minutes, can repeat 1/4 to 1/2 dose of Telazol once SC. Maintenance: O2/sevoflurane via mask/endotracheal tube to effect, maintain body temperature, monitor, provide fluid support and supplemental oxygen. Recovery: Maintain heat and fluid support. Pain control: Butorphanol 0.2 mg/kg q six to eight hrs SC. Dosages are suggested guidelines onlytailor actual amounts to individual patient needs.
PAGE 117
Exotic Patient Anesthesia Monitoring Form

Date: __________ Species: ______________ Weight: Temp: Date of Birth: Pulse: Procedure(s): Resp:
Pets Name: ___________________________
Pre-Meds
Acepromazine Dose:________ mg/kg x ________ kg / ________ mg/ml = ml

(1.0 mg/ml)
Rt of admin: Rt of admin: Rt of admin: Rt of admin: Rt of admin: Rt of admin: Rt of admin:
SC or IM
circle one
Butorphanol Midazolam Diazepam
Dose:________ mg/kg x ________ kg / ________ mg/ml = ml Dose:________ mg/kg x ________ kg / ________ mg/ml = ml Dose:________ mg/kg x ________ kg / ________ mg/ml = ml
SC or IM
circle one
SC or IM
circle one
SC or IM
circle one
Glycopyrrolate Dose:________ mg/kg x ________ kg / ________ mg/ml = ml Atropine Other Dose:________ mg/kg x ________ kg / ________ mg/ml = ml Dose:________ mg/kg x ________ kg / ________ mg/ml = ml
SC or IM
circle one
SC or IM
circle one
SC or IM
circle one
Name of Agent: ______________________________________________________________________________________________ Evaluation after pre-meds prior to induction Temp: Pulse rate: Sedation:
none / mild / adeq / excessive
circle one
Pulse quality:
Resp:
Induction
Propofol
(1.0 mg/ml)
Amount given
Dose:________ mg/kg x ________ kg / ________ mg/ml = ml Dose:________ mg/kg x ________ kg / ________ mg/ml = ml Dose:________ mg/kg x ________ kg / ________ mg/ml = ml
Rt of admin:
IV
circle one
Telazol Ketamine
Rt of admin:
SC or IM
circle one
Rt of admin:
SC or IM
circle one
PAGE 118
Exotic Patient Anesthesia Monitoring Form (cont'd)

Time Sx started: Fluid type & rate: Time S ended: Total vol. fluid admin: Induction 5 min 10 min 15 min Extubated: Catheter size: 20 min 25 min Sternal: Tracheal tube size: 30 min 35 min 40 min 45 min
ml/hr
Sevo% O2 flow (L/min) Heart rate Pulse Ox O2 Respiratory rate CRT/memb. color Pulse quality ECG rhythm BP Temperature
50 min 55 min 60 min 65 min 70 min 75 min 80 min 85 min 90 min 95 min
Sevo% O2 flow (L/min) Heart rate Pulse Ox O2 Respiratory rate CRT/memb. color Pulse quality ECG rhythm BP Temperature Antibiotic given: Pain Med. given:
Amt. given: Amt. given: Time given: Time given: Pain Meds. Rxed:
PAGE 119

Bob, Tim and Gerber
PAGE 120
Dr. Gonzales and Cecilia
Appendix
Section 5:
Appendix
Appendix
PAGE 121
ACEPROMAZINE 1 mg/ml*
Dose: 0.025 mg/lb for Anesthesia Protocol Maximum single dose is 1.5 mg Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 12.7 13.2 13.6 ml to administer 0.03 0.05 0.08 0.10 0.13 0.15 0.18 0.20 0.23 0.25 0.28 0.30 0.33 0.35 0.38 0.40 0.43 0.45 0.48 0.50 0.53 0.55 0.58 0.60 0.63 0.65 0.68 0.70 0.73 0.75 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Pet wt. Pet wt. lbs kg 31 14.1 32 14.5 33 15.0 34 15.5 35 15.9 36 16.4 37 16.8 38 17.3 39 17.7 40 18.2 41 18.6 42 19.1 43 19.5 44 20.0 45 20.5 46 20.9 47 21.4 48 21.8 49 22.3 50 22.7 51 23.2 52 23.6 53 24.1 54 24.5 55 25.0 56 25.5 57 25.9 58 26.4 59 26.8 60 27.3 >60 >27.3
ml to administer 0.78 0.80 0.83 0.85 0.88 0.90 0.93 0.95 0.98 1.00 1.03 1.05 1.08 1.10 1.13 1.15 1.18 1.20 1.23 1.25 1.28 1.30 1.33 1.35 1.38 1.40 1.43 1.45 1.48 1.50 1.50 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
*Acepromazine should be pre-diluted to 1 mg/ml to better allow proper drug measurement. Directions: Order sterile water for injection and 30 ml empty sterile vials through Banfield Direct. Draw 27 ml of sterile water with a sterile syringe and add it to the empty sterile vial. Draw 3 ml of 10 mg/ml acepromazine and add to the same vialthis will result in a 1 mg/ml solution. Vial should be labeled appropriately and dated. The solution is light-sensitive. Protect it from light by wrapping the vial completely. If protected from light, the solution is stable at room temperature. Maximum dose of acepromazine: 1 mg/ml is 1.5 ml.
Appendix
PAGE 122
Appendix
BUTORPHANOL 10 mg/ml
Dose: 0.1 to 0.2 mg/lb for Anesthesia Protocol Maximum single dose is 5 mg* Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 ml to administer 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09 0.10 0.11 0.12 0.13 0.14 0.15 0.16 0.17 0.18 0.19 0.20 0.21 0.22 0.23 0.24 0.25 0.26 0.27 to to to to to to to to to to to to to to to to to to to to to to to to to to to 0.02 0.04 0.06 0.08 0.10 0.12 0.14 0.16 0.18 0.20 0.22 0.24 0.26 0.28 0.30 0.32 0.34 0.36 0.38 0.40 0.42 0.44 0.46 0.48 0.50 0.50 0.50 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Pet wt. lbs 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 >50
Pet wt. kg 12.7 13.2 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 >22.7
ml to administer 0.28 0.29 0.30 0.31 0.32 0.33 0.34 0.35 0.36 0.37 0.38 0.39 0.40 0.41 0.42 0.43 0.44 0.45 0.46 0.47 0.48 0.49 0.50 to to to to to to to to to to to to to to to to to to to to to to to 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
*Maximum single dose is 0.5 ml. Butorphanol dose can be repeated as needed every one to two hours for pain management.
Appendix
PAGE 123
DIAZEPAM 5 mg/ml
Dose: 0.1 mg/lb for Anesthesia Protocol Maximum single dose is 10 mg Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 12.7 ml to administer 0.02 0.04 0.06 0.08 0.10 0.12 0.14 0.16 0.18 0.20 0.22 0.24 0.26 0.28 0.30 0.32 0.34 0.36 0.38 0.40 0.42 0.44 0.46 0.48 0.50 0.52 0.54 0.56 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Pet wt. lbs 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73
Pet wt. kg 13.2 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0 30.5 30.9 31.4 31.8 32.3 32.7 33.2
ml to administer 0.58 0.60 0.62 0.64 0.66 0.68 0.70 0.72 0.74 0.76 0.78 0.80 0.82 0.84 0.86 0.88 0.90 0.92 0.94 0.96 0.98 1.00 1.02 1.04 1.06 1.08 1.10 1.12 1.14 1.16 1.18 1.20 1.22 1.24 1.26 1.28 1.30 1.32 1.34 1.36 1.38 1.40 1.42 1.44 1.46 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Pet wt. lbs 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 >100
Pet wt. kg 33.6 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5 >45.5
ml to administer 1.48 1.50 1.52 1.54 1.56 1.58 1.60 1.62 1.64 1.66 1.68 1.70 1.72 1.74 1.76 1.78 1.80 1.82 1.84 1.86 1.88 1.90 1.92 1.94 1.96 1.98 2.00 2.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
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Appendix
DIPHENHYDRAMINE
50 mg/ml
Dose: 1 mg/lb for Anesthesia Protocol Maximum single dose is 50 mg Pet wt. lbs Pet wt. kg 1 0.5 2 0.9 3 1.4 4 1.8 5 2.3 6 2.7 7 3.2 8 3.6 9 4.1 10 4.5 11 5.0 12 5.5 13 5.9 14 6.4 15 6.8 16 7.3 17 7.7 18 8.2 19 8.6 20 9.1 21 9.5 22 10.0 23 10.5 24 10.9 25 11.4 26 11.8 27 12.3 ml to administer 0.02 0.04 0.06 0.08 0.10 0.12 0.14 0.16 0.18 0.20 0.22 0.24 0.26 0.28 0.30 0.32 0.34 0.36 0.38 0.40 0.42 0.44 0.46 0.48 0.50 0.52 0.54 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Pet wt. lbs Pet wt. kg 28 12.7 29 13.2 30 13.6 31 14.1 32 14.5 33 15.0 34 15.5 35 15.9 36 16.4 37 16.8 38 17.3 39 17.7 40 18.2 41 18.6 42 19.1 43 19.5 44 20.0 45 20.5 46 20.9 47 21.4 48 21.8 49 22.3 50 22.7 >50 >22.7
ml to administer 0.56 0.58 0.60 0.62 0.64 0.66 0.68 0.70 0.72 0.74 0.76 0.78 0.80 0.82 0.84 0.86 0.88 0.90 0.92 0.94 0.96 0.98 1.00 1.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
Appendix
PAGE 125
MORPHINE 10 mg/ml
For Anesthesia Protocol DOSE FOR DOGS: 0.2 to 0.5 mg/lb *Maximum single dose is 5 mg. DOSE FOR CATS: 0.05 to 0.15 mg/lb *Maximum single dose is 2.5 mg. Dose for Dogs Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 >25 Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 >11.4 ml to administer
0.2 mg/lb 0.5 mg/lb
Dose for Cats ml to administer

0.05 mg/lb 0.15 mg/lb
0.02 0.04 0.06 0.08 0.10 0.12 0.14 0.16 0.18 0.20 0.22 0.24 0.26 0.28 0.30 0.32 0.34 0.36 0.38 0.40 0.42 0.44 0.46 0.48 0.50 0.50
to to to to to to to to to to to to to to to to to to to to to to to to to to
0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50 0.50
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
0.01 0.01 0.02 0.02 0.03 0.03 0.04 0.04 0.05 0.05 0.06 0.06 0.07 0.07 0.08 0.08 0.09 0.09 0.10 0.10 0.11 0.11 0.12 0.12 0.13 0.13
0.02 0.03 0.05 0.06 0.08 0.09 0.11 0.12 0.14 0.15 0.17 0.18 0.20 0.21 0.23 0.24 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25
Appendix
*Morphine dose can be repeated as needed every four to six hours for pain management if cardiovascular system is stable.
PAGE 126
Appendix
PROPOFOL 10 mg/ml
For Anesthesia Protocol Dose: 1 to 4 mg/lb Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Pet ml @ 1 mg/lb ml @ 2 mg/lb wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 12.7 13.2 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 1.10 1.20 1.30 1.40 1.50 1.60 1.70 1.80 1.90 2.00 2.10 2.20 2.30 2.40 2.50 2.60 2.70 2.80 2.90 3.00 3.10 3.20 3.30 3.40 3.50 3.60 3.70 3.80 3.90 4.00 4.10 4.20 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00 2.20 2.40 2.60 2.80 3.00 3.20 3.40 3.60 3.80 4.00 4.20 4.40 4.60 4.80 5.00 5.20 5.40 5.60 5.80 6.00 6.20 6.40 6.60 6.80 7.00 7.20 7.40 7.60 7.80 8.00 8.20 8.40 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 3 mg/lb 0.30 0.60 0.90 1.20 1.50 1.80 2.10 2.40 2.70 3.00 3.30 3.60 3.90 4.20 4.50 4.80 5.10 5.40 5.70 6.00 6.30 6.60 6.90 7.20 7.50 7.80 8.10 8.40 8.70 9.00 9.30 9.60 9.90 10.20 10.50 10.80 11.10 11.40 11.70 12.00 12.30 12.60 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 4 mg/lb 0.40 0.80 1.20 1.60 2.00 2.40 2.80 3.20 3.60 4.00 4.40 4.80 5.20 5.60 6.00 6.40 6.80 7.20 7.60 8.00 8.40 8.80 9.20 9.60 10.00 10.40 10.80 11.20 11.60 12.00 12.40 12.80 13.20 13.60 14.00 14.40 14.80 15.20 15.60 16.00 16.40 16.80 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Propofol given too rapidly and/or at too high a dose can cause apnea and bradycardia. Give a third of the calculated dose over five to 10 seconds, assess effect for 15 seconds, give additional small volumes and assess again to effect.
Appendix
Appendix
PAGE 127
PROPOFOL 10 mg/ml (contd)

For Anesthesia Protocol Dose: 1 to 4 mg/lb Pet wt. lbs 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 Pet wt. kg 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0 30.5 30.9 31.4 31.8 32.3 32.7 33.2 33.6 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 ml @ 1 mg/lb ml @ 2 mg/lb 4.30 4.40 4.50 4.60 4.70 4.80 4.90 5.00 5.10 5.20 5.30 5.40 5.50 5.60 5.70 5.80 5.90 6.00 6.10 6.20 6.30 6.40 6.50 6.60 6.70 6.80 6.90 7.00 7.10 7.20 7.30 7.40 7.50 7.60 7.70 7.80 7.90 8.00 8.10 8.20 8.30 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml 8.60 8.80 9.00 9.20 9.40 9.60 9.80 10.00 10.20 10.40 10.60 10.80 11.00 11.20 11.40 11.60 11.80 12.00 12.20 12.40 12.60 12.80 13.00 13.20 13.40 13.60 13.80 14.00 14.20 14.40 14.60 14.80 15.00 15.20 15.40 15.60 15.80 16.00 16.20 16.40 16.60 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 3 mg/lb 12.90 13.20 13.50 13.80 14.10 14.40 14.70 15.00 15.30 15.60 15.90 16.20 16.50 16.80 17.10 17.40 17.70 18.00 18.30 18.60 18.90 19.20 19.50 19.80 20.10 20.40 20.70 21.00 21.30 21.60 21.90 22.20 22.50 22.80 23.10 23.40 23.70 24.00 24.30 24.60 24.90 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 4 mg/lb 17.20 17.60 18.00 18.40 18.80 19.20 19.60 20.00 20.40 20.80 21.20 21.60 22.00 22.40 22.80 23.20 23.60 24.00 24.40 24.80 25.20 25.60 26.00 26.40 26.80 27.20 27.60 28.00 28.40 28.80 29.20 29.60 30.00 30.40 30.80 31.20 31.60 32.00 32.40 32.80 33.20 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
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Appendix
PROPOFOL 10 mg/ml (contd)

For Anesthesia Protocol Dose: 1 to 4 mg/lb Pet wt. lbs 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Pet wt. kg 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5 ml @ 1 mg/lb 8.40 8.50 8.60 8.70 8.80 8.90 9.00 9.10 9.20 9.30 9.40 9.50 9.60 9.70 9.80 9.90 10.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 2 mg/lb 16.80 17.00 17.20 17.40 17.60 17.80 18.00 18.20 18.40 18.60 18.80 19.00 19.20 19.40 19.60 19.80 20.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 3 mg/lb 25.20 25.50 25.80 26.10 26.40 26.70 27.00 27.30 27.60 27.90 28.20 28.50 28.80 29.10 29.40 29.70 30.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 4 mg/lb 33.60 34.00 34.40 34.80 35.20 35.60 36.00 36.40 36.80 37.20 37.60 38.00 38.40 38.80 39.20 39.60 40.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
Appendix
PAGE 129
TELAZOL 100 mg/ml

Dose: 0.5 to 2 mg/lb IM for immobilization and 0.5 to 1 mg/lb IV for induction with Anesthesia Protocols Maximum single dose for immobilization is 100 mg. Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 12.7 13.2 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 ml @ 0.5 mg/lb 0.01 0.01 0.02 0.02 0.03 0.03 0.04 0.04 0.05 0.05 0.06 0.06 0.07 0.07 0.08 0.08 0.09 0.09 0.10 0.10 0.11 0.11 0.12 0.12 0.13 0.13 0.14 0.14 0.15 0.15 0.16 0.16 0.17 0.17 0.18 0.18 0.19 0.19 0.20 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 1 mg/lb 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09 0.10 0.11 0.12 0.13 0.14 0.15 0.16 0.17 0.18 0.19 0.20 0.21 0.22 0.23 0.24 0.25 0.26 0.27 0.28 0.29 0.30 0.31 0.32 0.33 0.34 0.35 0.36 0.37 0.38 0.39 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 1.5 mg/lb 0.02 0.03 0.05 0.06 0.08 0.09 0.11 0.12 0.14 0.15 0.17 0.18 0.20 0.21 0.23 0.24 0.26 0.27 0.29 0.30 0.32 0.33 0.35 0.36 0.38 0.39 0.41 0.42 0.44 0.45 0.47 0.48 0.50 0.51 0.53 0.54 0.56 0.57 0.59 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 2 mg/lb 0.02 0.04 0.06 0.08 0.10 0.12 0.14 0.16 0.18 0.20 0.22 0.24 0.26 0.28 0.30 0.32 0.34 0.36 0.38 0.40 0.42 0.44 0.46 0.48 0.50 0.52 0.54 0.56 0.58 0.60 0.62 0.64 0.66 0.68 0.70 0.72 0.74 0.76 0.78 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Maximum single dose for immobilization is 1 ml. If, after 15 to 20 minutes, effects of medication are not adequate for restraint, the dose can be repeated up to a total dose of 2 mg/lb.
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Appendix
TELAZOL 100 mg/ml (contd)

Dose: 0.5 to 2 mg/lb IM for immobilization and 0.5 to 1 mg/lb IV for induction with Anesthesia Protocols Maximum single dose for immobilization is 100 mg. Pet wt. lbs 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 Pet wt. kg 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0 30.5 30.9 31.4 31.8 32.3 32.7 33.2 33.6 34.1 34.5 35.0 35.5 35.9 36.4 ml @ 0.5 mg/lb 0.20 0.21 0.21 0.22 0.22 0.23 0.23 0.24 0.24 0.25 0.25 0.26 0.26 0.27 0.27 0.28 0.28 0.29 0.29 0.30 0.30 0.31 0.31 0.32 0.32 0.33 0.33 0.34 0.34 0.35 0.35 0.36 0.36 0.37 0.37 0.38 0.38 0.39 0.39 0.40 0.40 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 1 mg/lb 0.40 0.41 0.42 0.43 0.44 0.45 0.46 0.47 0.48 0.49 0.50 0.51 0.52 0.53 0.54 0.55 0.56 0.57 0.58 0.59 0.60 0.61 0.62 0.63 0.64 0.65 0.66 0.67 0.68 0.69 0.70 0.71 0.72 0.73 0.74 0.75 0.76 0.77 0.78 0.79 0.80 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 1.5 mg/lb 0.60 0.62 0.63 0.65 0.66 0.68 0.69 0.71 0.72 0.74 0.75 0.77 0.78 0.80 0.81 0.83 0.84 0.86 0.87 0.89 0.90 0.92 0.93 0.95 0.96 0.98 0.99 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 2 mg/lb 0.80 0.82 0.84 0.86 0.88 0.90 0.92 0.94 0.96 0.98 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
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Appendix
PAGE 131
TELAZOL 100 mg/ml (contd)

Dose: 0.5 to 2 mg/lb IM for immobilization and 0.5 to 1 mg/lb IV for induction with Anesthesia Protocols Maximum single dose for immobilization is 100 mg. Pet wt. lbs 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Pet wt. kg 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5 ml @ 0.5 mg/lb 0.41 0.41 0.42 0.42 0.43 0.43 0.44 0.44 0.45 0.45 0.46 0.46 0.47 0.47 0.48 0.48 0.49 0.49 0.50 0.50 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 1 mg/lb 0.81 0.82 0.83 0.84 0.85 0.86 0.87 0.88 0.89 0.90 0.91 0.92 0.93 0.94 0.95 0.96 0.97 0.98 0.99 1.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 1.5 mg/lb 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml @ 2 mg/lb 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
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Appendix
KETOPROFEN 100 mg/ml Post-op analgesia

Dose: 0.9 mg/lb Day 1; then 0.45 mg/lb Days 2 to 5 for post-op analgesia Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 0.9 mg/ lb-day 1 0.01 ml 0.02 ml 0.03 ml 0.04 ml 0.05 ml 0.05 ml 0.06 ml 0.07 ml 0.08 ml 0.09 ml 0.10 ml 0.11 ml 0.12 ml 0.13 ml 0.14 ml 0.15 ml 0.15 ml 0.16 ml 0.17 ml 0.18 ml 0.19 ml 0.20 ml 0.21 ml 0.22 ml 0.45 mg/lb day 2-5 0.00 ml 0.01 ml 0.01 ml 0.02 ml 0.02 ml 0.03 ml 0.03 ml 0.04 ml 0.04 ml 0.05 ml 0.05 ml 0.05 ml 0.06 ml 0.06 ml 0.07 ml 0.07 ml 0.08 ml 0.08 ml 0.09 ml 0.09 ml 0.10 ml 0.10 ml 0.10 ml 0.11 ml
Pet wt. lbs 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66
Pet wt. kg 11.4 11.8 12.3 12.7 13.2 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0
0.9 mg/ lb-day 1 0.23 ml 0.23 ml 0.24 ml 0.25 ml 0.26 ml 0.27 ml 0.28 ml 0.29 ml 0.30 ml 0.31 ml 0.32 ml 0.32 ml 0.33 ml 0.34 ml 0.35 ml 0.36 ml 0.37 ml 0.38 ml 0.39 ml 0.40 ml 0.41 ml 0.41 ml 0.42 ml 0.43 ml 0.44 ml 0.45 ml 0.46 ml 0.47 ml 0.48 ml 0.49 ml 0.50 ml 0.50 ml 0.51 ml 0.52 ml 0.53 ml 0.54 ml 0.55 ml 0.56 ml 0.57 ml 0.58 ml 0.59 ml 0.59 ml
0.45 mg/lb day 2-5 0.11 ml 0.12 ml 0.12 ml 0.13 ml 0.13 ml 0.14 ml 0.14 ml 0.15 ml 0.15 ml 0.15 ml 0.16 ml 0.16 ml 0.17 ml 0.17 ml 0.18 ml 0.18 ml 0.19 ml 0.19 ml 0.20 ml 0.20 ml 0.20 ml 0.21 ml 0.21 ml 0.22 ml 0.22 ml 0.23 ml 0.23 ml 0.24 ml 0.24 ml 0.25 ml 0.25 ml 0.25 ml 0.26 ml 0.26 ml 0.27 ml 0.27 ml 0.28 ml 0.28 ml 0.29 ml 0.29 ml 0.30 ml 0.30 ml
Pet wt. lbs 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Pet wt. kg 30.5 30.9 31.4 31.8 32.3 32.7 33.2 33.6 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5
0.9 mg/ lb-day 1 0.61 ml 0.61 ml 0.62 ml 0.63 ml 0.64 ml 0.65 ml 0.66 ml 0.67 ml 0.68 ml 0.68 ml 0.69 ml 0.70 ml 0.71 ml 0.72 ml 0.73 0.74 0.75 0.76 0.77 0.77 0.78 0.79 0.80 0.81 0.82 0.83 0.84 0.85 0.85 0.86 0.87 0.88 0.89 0.90 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
0.45 mg/lb day 2-5 0.30 ml 0.31 ml 0.31 ml 0.32 ml 0.32 ml 0.33 ml 0.33 ml 0.34 ml 0.34 ml 0.35 ml 0.35 ml 0.35 ml 0.36 ml 0.36 ml 0.37 0.37 0.38 0.38 0.39 0.39 0.40 0.40 0.40 0.41 0.41 0.42 0.42 0.43 0.43 0.44 0.44 0.45 0.45 0.45 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
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PAGE 133
AMEP
*ATROPINE 0.54 mg/ml

Dose: 0.01 mg/lb for Anesthesia Monitoring and Emergency Protocol administer slowly to effect.
* Atropine can cause an initial slowing of the heart rate that usually responds within a few seconds.
Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9
Appendix
Pet wt. lbs 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69
Pet wt. kg 11.4 11.8 12.3 12.7 13.2 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0 30.5 30.9 31.4
Pet wt. lbs 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Pet wt. kg 31.8 32.3 32.7 33.2 33.6 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5
ml to administer 1.30 1.31 1.33 1.35 1.37 1.39 1.41 1.43 1.44 1.46 1.48 1.50 1.52 1.54 1.56 1.57 1.59 1.61 1.63 1.65 1.67 1.69 1.70 1.72 1.74 1.76 1.78 1.80 1.81 1.83 1.85 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
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Appendix
*GLYCOPYRROLATE
0.2 mg/mlAMEP
Dose: 0.005 mg/lb for Anesthesia Monitoring and Emergency Protocol
* Glycopyrrolate can cause an initial slowing of the heart rate when given IV.
Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9
Pet wt. lbs 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68
Pet wt. kg 11.4 11.8 12.3 12.7 13.2 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0 30.5 30.9
ml to administer 0.63 0.65 0.68 0.70 0.73 0.75 0.78 0.80 0.83 0.85 0.88 0.90 0.93 0.95 0.98 1.00 1.03 1.05 1.08 1.10 1.13 1.15 1.18 1.20 1.23 1.25 1.28 1.30 1.33 1.35 1.38 1.40 1.43 1.45 1.48 1.50 1.53 1.55 1.58 1.60 1.63 1.65 1.68 1.70 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Pet wt. lbs 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Pet wt. kg 31.4 31.8 32.3 32.7 33.2 33.6 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5
ml to administer 1.73 1.75 1.78 1.80 1.83 1.85 1.88 1.90 1.93 1.95 1.98 2.00 2.03 2.05 2.08 2.10 2.13 2.15 2.18 2.20 2.23 2.25 2.28 2.30 2.33 2.35 2.38 2.40 2.43 2.45 2.48 2.50 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
Appendix
PAGE 135
Pet wt. Pet wt. lbs kg 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 10.9 11.4 11.8 12.3 12.7 13.2 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0
ml to administer
0.05 mg/lb 2.5 mg/lb
Pet wt. Pet wt. lbs kg ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 30.5 30.9 31.4 31.8 32.3 32.7 33.2 33.6 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5
ml to administer
EPHEDRINE 5 mg/ml*AMEP
Dose: 0.05 to 2.5 mg/lb for Anesthesia Monitoring and Emergency Protocol Limit to three dosesstart at low end.
* Stock solution is 50 mg/ml (0.1 ml stock solution added to 0.9 ml of sterile saline = 5 mg/ml solution)
Pet wt. Pet wt. lbs kg 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5
ml to administer
0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09 0.10 0.11 0.12 0.13 0.14 0.15 0.16 0.17 0.18 0.19 0.20 0.21 0.22 0.23
to to to to to to to to to to to to to to to to to to to to to to to
0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0 11.5
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
0.24 0.25 0.26 0.27 0.28 0.29 0.30 0.31 0.32 0.33 0.34 0.35 0.36 0.37 0.38 0.39 0.40 0.41 0.42 0.43 0.44 0.45 0.46 0.47 0.48 0.49 0.50 0.51 0.52 0.53 0.54 0.55 0.56 0.57 0.58 0.59 0.60 0.61 0.62 0.63 0.64 0.65 0.66
to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to
12.0 12.5 13.0 13.5 14.0 14.5 15.0 15.5 16.0 16.5 17.0 17.5 18.0 18.5 19.0 19.5 20.0 20.5 21.0 21.5 22.0 22.5 23.0 23.5 24.0 24.5 25.0 25.5 26.0 26.5 27.0 27.5 28.0 28.5 29.0 29.5 30.0 30.5 31.0 31.5 32.0 32.5 33.0
0.67 0.68 0.69 0.70 0.71 0.72 0.73 0.74 0.75 0.76 0.77 0.78 0.79 0.80 0.81 0.82 0.83 0.84 0.85 0.86 0.87 0.88 0.89 0.90 0.91 0.92 0.93 0.94 0.95 0.96 0.97 0.98 0.99 1.00
to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to
33.5 34.0 34.5 35.0 35.5 36.0 36.5 37.0 37.5 38.0 38.5 39.0 39.5 40.0 40.5 41.0 41.5 42.0 42.5 43.0 43.5 44.0 44.5 45.0 45.5 46.0 46.5 47.0 47.5 48.0 48.5 49.0 49.5 50.0
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
PAGE 136
Appendix
LIDOCAINE 20 mg/ml BOLUSAMEP & CPR*

Dose: Dog: 1 to 2 mg/lb; Cat: 0.125 to 0.25 mg/lb administer slowly to effect Note: Can cause bradycardia
* Lidocaine dose is the same for both AMEP and CPR charts.
Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 12.7 13.2 13.6
Dose for Dogs ml to administer

1 mg/lb 2 mg/lb
Dose for Cats ml to administer

0.125 mg/lb 0.25 mg/lb
0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 0.50 0.55 0.60 0.65 0.70 0.75 0.80 0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20 1.25 1.30 1.35 1.40 1.45 1.50
to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to
0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 1.10 1.20 1.30 1.40 1.50 1.60 1.70 1.80 1.90 2.00 2.10 2.20 2.30 2.40 2.50 2.60 2.70 2.80 2.90 3.00
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
0.01 0.01 0.02 0.03 0.03 0.04 0.04 0.05 0.06 0.06 0.07 0.08 0.08 0.09 0.09 0.10 0.11 0.11 0.12 0.13 0.13 0.14 0.14 0.15 0.16 0.16 0.17 0.18 0.18 0.19
0.01 0.03 0.04 0.05 0.06 0.08 0.09 0.10 0.11 0.13 0.14 0.15 0.16 0.18 0.19 0.20 0.21 0.23 0.24 0.25 0.26 0.28 0.29 0.30 0.31 0.33 0.34 0.35 0.36 0.38
Appendix
Appendix
PAGE 137
LIDOCAINE 20 mg/ml BOLUSAMEP & CPR* (cont'd)

Dose: Dog: 1 to 2 mg/lb; Cat: 0.125 to 0.25 mg/lb administer slowly to effect Note: Can cause bradycardia
* Lidocaine dose is the same for both AMEP and CPR charts.
Pet wt. lbs 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66
Pet wt. kg 14 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0

1 mg/lb 2 mg/lb
Pet wt. lbs ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Pet wt. kg 30.5 30.9 31.4 31.8 32.3 32.7 33.2 33.6 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5

1 mg/lb 2 mg/lb
1.55 1.60 1.65 1.70 1.75 1.80 1.85 1.90 1.95 2.00 2.05 2.10 2.15 2.20 2.25 2.30 2.35 2.40 2.45 2.50 2.55 2.60 2.65 2.70 2.75 2.80 2.85 2.90 2.95 3.00 3.05 3.10 3.15 3.20 3.25 3.30
to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to
3.10 3.20 3.30 3.40 3.50 3.60 3.70 3.80 3.90 4.00 4.10 4.20 4.30 4.40 4.50 4.60 4.70 4.80 4.90 5.00 5.10 5.20 5.30 5.40 5.50 5.60 5.70 5.80 5.90 6.00 6.10 6.20 6.30 6.40 6.50 6.60
3.35 3.40 3.45 3.50 3.55 3.60 3.65 3.70 3.75 3.80 3.85 3.90 3.95 4.00 4.05 4.10 4.15 4.20 4.25 4.30 4.35 4.40 4.45 4.50 4.55 4.60 4.65 4.70 4.75 4.80 4.85 4.90 4.95 5.00
to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to
6.70 6.80 6.90 7.00 7.10 7.20 7.30 7.40 7.50 7.60 7.70 7.80 7.90 8.00 8.10 8.20 8.30 8.40 8.50 8.60 8.70 8.80 8.90 9.00 9.10 9.20 9.30 9.40 9.50 9.60 9.70 9.80 9.90 10.00
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
PAGE 138
Appendix
4mg/mlCPR
Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
DEXAMETHASONE SP
Dose: 2 mg/lb IV Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 12.7 13.2 13.6 ml to administer 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00 5.50 6.00 6.50 7.00 7.50 8.00 8.50 9.00 9.50 10.00 10.50 11.00 11.50 12.00 12.50 13.00 13.50 14.00 14.50 15.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Pet wt. lbs 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75
Pet wt. kg 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0 30.5 30.9 31.4 31.8 32.3 32.7 33.2 33.6 34.1
Pet wt. lbs 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Pet wt. kg 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5
ml to administer 38.00 38.50 39.00 39.50 40.00 40.50 41.00 41.50 42.00 42.50 43.00 43.50 44.00 44.50 45.00 45.50 46.00 46.50 47.00 47.50 48.00 48.50 49.00 49.50 50.00 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
Appendix
PAGE 139
ATROPINE 0.54 mg/mlCPR

Dose: 0.01 to 0.02 mg/lb IV for Cardiopulmonary Resuscitation Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 12.7 13.2 ml to administer 0.02 0.04 0.06 0.07 0.09 0.11 0.13 0.15 0.17 0.19 0.20 0.22 0.24 0.26 0.28 0.30 0.31 0.33 0.35 0.37 0.39 0.41 0.43 0.44 0.46 0.48 0.50 0.52 0.54 to to to to to to to to to to to to to to to to to to to to to to to to to to to to to 0.04 0.07 0.11 0.15 0.19 0.22 0.26 0.30 0.33 0.37 0.41 0.44 0.48 0.52 0.56 0.59 0.63 0.67 0.70 0.74 0.78 0.81 0.85 0.89 0.93 0.96 1.00 1.04 1.07 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Pet wt. lbs 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73
Pet wt. kg 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0 30.5 30.9 31.4 31.8 32.3 32.7 33.2
ml to administer 0.56 0.57 0.59 0.61 0.63 0.65 0.67 0.69 0.70 0.72 0.74 0.76 0.78 0.80 0.81 0.83 0.85 0.87 0.89 0.91 0.93 0.94 0.96 0.98 1.00 1.02 1.04 1.06 1.07 1.09 1.11 1.13 1.15 1.17 1.19 1.20 1.22 1.24 1.26 1.28 1.30 1.31 1.33 1.35 to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to 1.11 1.15 1.19 1.22 1.26 1.30 1.33 1.37 1.41 1.44 1.48 1.52 1.56 1.59 1.63 1.67 1.70 1.74 1.78 1.81 1.85 1.89 1.93 1.96 2.00 2.04 2.07 2.11 2.15 2.19 2.22 2.26 2.30 2.33 2.37 2.41 2.44 2.48 2.52 2.56 2.59 2.63 2.67 2.70 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Pet wt. lbs 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Pet wt. kg 33.6 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5
ml to administer 1.37 1.39 1.41 1.43 1.44 1.46 1.48 1.50 1.52 1.54 1.56 1.57 1.59 1.61 1.63 1.65 1.67 1.69 1.70 1.72 1.74 1.76 1.78 1.80 1.81 1.83 1.85 to to to to to to to to to to to to to to to to to to to to to to to to to to to 2.74 2.78 2.81 2.85 2.89 2.93 2.96 3.00 3.04 3.07 3.11 3.15 3.19 3.22 3.26 3.30 3.33 3.37 3.41 3.44 3.48 3.52 3.56 3.59 3.63 3.67 3.70 ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
PAGE 140
Appendix
Pet wt. lbs Pet wt. kg 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 14 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0 30.5 30.9 31.4 31.8 32.3 32.7 33.2 33.6
Low Dose ml to administer

0.005 mg/lb 0.01 mg/lb
High Dose
0.1 mg/lb
EPINEPHRINE 1:1,000 = 1 mg/mlCPR

Low Dose: 0.005 to 0.01 mg/lb IVHigh Dose: 0.1 mg/lb IV for Cardiopulmonary Resuscitation Pet wt. lbs Pet wt. kg 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 12.7 13.2 13.6 Low Dose ml to administer
0.005 mg/lb 0.01 mg/lb
High Dose
0.1 mg/lb
0.01 0.01 0.02 0.02 0.03 0.03 0.04 0.04 0.05 0.05 0.06 0.06 0.07 0.07 0.08 0.08 0.09 0.09 0.10 0.10 0.11 0.11 0.12 0.12 0.13 0.13 0.14 0.14 0.15 0.15
0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09 0.10 0.11 0.12 0.13 0.14 0.15 0.16 0.17 0.18 0.19 0.20 0.21 0.22 0.23 0.24 0.25 0.26 0.27 0.28 0.29 0.30
0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 1.10 1.20 1.30 1.40 1.50 1.60 1.70 1.80 1.90 2.00 2.10 2.20 2.30 2.40 2.50 2.60 2.70 2.80 2.90 3.00
0.16 0.16 0.17 0.17 0.18 0.18 0.19 0.19 0.20 0.20 0.21 0.21 0.22 0.22 0.23 0.23 0.24 0.24 0.25 0.25 0.26 0.26 0.27 0.27 0.28 0.28 0.29 0.29 0.30 0.30 0.31 0.31 0.32 0.32 0.33 0.33 0.34 0.34 0.35 0.35 0.36 0.36 0.37 0.37
to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to
0.31 0.32 0.33 0.34 0.35 0.36 0.37 0.38 0.39 0.40 0.41 0.42 0.43 0.44 0.45 0.46 0.47 0.48 0.49 0.50 0.51 0.52 0.53 0.54 0.55 0.56 0.57 0.58 0.59 0.60 0.61 0.62 0.63 0.64 0.65 0.66 0.67 0.68 0.69 0.70 0.71 0.72 0.73 0.74
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
3.10 3.20 3.30 3.40 3.50 3.60 3.70 3.80 3.90 4.00 4.10 4.20 4.30 4.40 4.50 4.60 4.70 4.80 4.90 5.00 5.10 5.20 5.30 5.40 5.50 5.60 5.70 5.80 5.90 6.00 6.10 6.20 6.30 6.40 6.50 6.60 6.70 6.80 6.90 7.00 7.10 7.20 7.30 7.40
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
Appendix
PAGE 141
EPINEPHRINE 1:1,000 = 1 mg/mlCPR (cont'd)

Low Dose: 0.005 to 0.01 mg/lb IVHigh Dose: 0.1 mg/lb IV for Cardiopulmonary Resuscitation Pet wt. lbs Pet wt. kg 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5 Low Dose ml to administer
0.005 mg/lb 0.01 mg/lb
High Dose
0.1 mg/lb
0.38 0.38 0.39 0.39 0.40 0.40 0.41 0.41 0.42 0.42 0.43 0.43 0.44 0.44 0.45 0.45 0.46 0.46 0.47 0.47 0.48 0.48 0.49 0.49 0.50 0.50
0.75 0.76 0.77 0.78 0.79 0.80 0.81 0.82 0.83 0.84 0.85 0.86 0.87 0.88 0.89 0.90 0.91 0.92 0.93 0.94 0.95 0.96 0.97 0.98 0.99 1.00
7.50 7.60 7.70 7.80 7.90 8.00 8.10 8.20 8.30 8.40 8.50 8.60 8.70 8.80 8.90 9.00 9.10 9.20 9.30 9.40 9.50 9.60 9.70 9.80 9.90 10.00
Appendix
PAGE 142
Appendix
Pet wt. lbs 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72
Pet wt. kg 12.7 13.2 13.6 14.1 14.5 15.0 15.5 15.9 16.4 16.8 17.3 17.7 18.2 18.6 19.1 19.5 20.0 20.5 20.9 21.4 21.8 22.3 22.7 23.2 23.6 24.1 24.5 25.0 25.5 25.9 26.4 26.8 27.3 27.7 28.2 28.6 29.1 29.5 30.0 30.5 30.9 31.4 31.8 32.3 32.7
ml to administer
5.60 5.80 6.00 6.20 6.40 6.60 6.80 7.00 7.20 7.40 7.60 7.80 8.00 8.20 8.40 8.60 8.80 9.00 9.20 9.40 9.60 9.80 10.00 10.20 10.40 10.60 10.80 11.00 11.20 11.40 11.60 11.80 12.00 12.20 12.40 12.60 12.80 13.00 13.20 13.40 13.60 13.80 14.00 14.20 14.40
to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to
12.60 13.05 13.50 13.95 14.40 14.85 15.30 15.75 16.20 16.65 17.10 17.55 18.00 18.45 18.90 19.35 19.80 20.25 20.70 21.15 21.60 22.05 22.50 22.95 23.40 23.85 24.30 24.75 25.20 25.65 26.10 26.55 27.00 27.45 27.90 28.35 28.80 29.25 29.70 30.15 30.60 31.05 31.50 31.95 32.40
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
SODIUM BICARBONATE 8.4%,

1 mEq/mlCPR
Dose: 0.2 to 0.45 mEq/lb Give slowly over five minutes. Pet wt. lbs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Pet wt. kg 0.5 0.9 1.4 1.8 2.3 2.7 3.2 3.6 4.1 4.5 5.0 5.5 5.9 6.4 6.8 7.3 7.7 8.2 8.6 9.1 9.5 10.0 10.5 10.9 11.4 11.8 12.3 ml to administer
0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00 2.20 2.40 2.60 2.80 3.00 3.20 3.40 3.60 3.80 4.00 4.20 4.40 4.60 4.80 5.00 5.20 5.40
to to to to to to to to to to to to to to to to to to to to to to to to to to to
0.45 0.90 1.35 1.80 2.25 2.70 3.15 3.60 4.05 4.50 4.95 5.40 5.85 6.30 6.75 7.20 7.65 8.10 8.55 9.00 9.45 9.90 10.35 10.80 11.25 11.70 12.15
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
Appendix
PAGE 143
SODIUM BICARBONATE 8.4%,

1 mEq/mlCPR (cont'd)
Dose: 0.2 to 0.45 mEq/lb Give slowly over five minutes. Pet wt. lbs 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Pet wt. kg ml to administer
33.2 33.6 34.1 34.5 35.0 35.5 35.9 36.4 36.8 37.3 37.7 38.2 38.6 39.1 39.5 40.0 40.5 40.9 41.4 41.8 42.3 42.7 43.2 43.6 44.1 44.5 45.0 45.5
14.60 to 14.80 to 15.00 15.20 15.40 15.60 15.80 16.00 16.20 16.40 16.60 16.80 17.00 17.20 17.40 17.60 17.80 18.00 18.20 18.40 18.60 18.80 19.00 19.20 19.40 19.60 19.80 20.00 to to to to to to to to to to to to to to to to to to to to to to to to to to
32.85 33.30 33.75 34.20 34.65 35.10 35.55 36.00 36.45 36.90 37.35 37.80 38.25 38.70 39.15 39.60 40.05 40.50 40.95 41.40 41.85 42.30 42.75 43.20 43.65 44.10 44.55 45.00
ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml ml
Appendix
PAGE 144
Appendix
Banfield 2008.12 #87135

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Anesthesia

for the Pet Practitioner

Dr. Patriquin and Korey

ANESTHESIa FOR THE PET PRaCTITIONER

Dr. Yarbrough and Samson

Dr. Faunt and Bogart

Dr. Hughes and Dublin

Linda and Baxter

Table 1: Banfield Anesthesia Mortality Data

Standards and protocols

Figure 1: Autonomic Nervous System: Drugs & Their Cardiovascular Effects

(-) Atropine (-) Glycopyrrolate

PerIPheral Nervous System

CENTRAL NERVOUS SYSTEM

(+) Medetomidine (+) Xylazine (-) Yohimbine

Heart increase HR, contractility, automaticity, conduction velocity Adipocytes lipolysis

THE AUTONOMIC NERVOUS SYSTEM

Parasympathetic cholinergic pathway

Alpha-1 sympathetic pathway

Central alpha-2 agonists

ANESTHESIA COMMITMENT DOCUMENT PERMISSION TO STOP!

Think. Make a good decision.

FRACTIOUS PETS Think. Make a good decision.

Figure 1.1: Good Perfusion & Receptor Sites

GENERAL REQUIREMENTS FOR ANESTHESIA AND DEFINITIONS General information

Definitions and requirements

Figure 1.2: Brachycephalic Breed (Bulldog)

Figure 1.3: Brachycephalic Breed (Persian)

Perioperative Antibiotic Best Practice Guidelines

Dr. Metcalf and Weewolf

Practice Standards for Multiple Procedure Anesthesia

Dr. Deckert, Hope and Hunter

1. Lascelles BDX, Roberston SA. Use of thermal threshold

Think. Make a good decision.

INDUCTION AGENTS (cont'd) Propofol

Telazol (Zolazepam and Tiletamine)

Intubation and airway management in cats

OXYGEN FLOW RATES DURING ANESTHESIA Rebreathing circuit

MAINTENANCE AGENT Sevoflurane

Non-rebreathing circuit (Bain's)

Three goals of monitoring

END TIDAL CO2

Signs of significant hypothermia

Preventing heat loss

Two methods for warming patients

ANESTHESIA MONITORING AND EMERGENCY PROTOCOL ALGORITHM

Our most commonly used drugs are as follows:

Butorphanol (Torbugesic) injectable

Butorphanol +/- diphenhydramine oral

1.3 to 1.8 mg/lb PO once daily for post-operative pain management.

Etodolac (Etogesic) oral (dogs only)

Carprofen (Rimadyl) oral (dogs only)

Ketoprofen (Ketofen) injectable

Deracoxib (Deramaxx) (dogs only)

Ketoprofen (Ketofen) oral

Protocol to treat Ketoprofen overdose - See SmartHelp

Clearance of NSAIDs Think. Make a good decision.

Next day 9 Next day

(in addition to local or regional nerve blocks when appropriate)

This level of pain can kill.

Moderate to Severe and Severe

(varies with degree of illness)