Is it safe to anesthetize my pet?
Best practices for anesthetizing pets. By Dr. Joi Sutton, DVM
Best practices for anesthetizing pets. By Dr. Joi Sutton, DVM
Dr. Joi Sutton is often asked if it is “safe to anesthetize” a pet, particularly senior pets. What many clients don’t understand is that there are many types of anesthetics, protocols, and monitoring. We treat even young pets as if they were high-risk patients. We are quite Type A when it comes to anesthesia. She likes to joke that though Type A people may not be the easiest folks to have in your life, we Type A personalities are the ones you want to anesthetize your pet! Compared to hospitals that do many procedures a day, this could be considered “boutique” anesthesia. We are perfectly fine with that description.
Dr. Sutton performs the majority of procedures at Tequesta Veterinary Clinic. Back in the 1990s Dr. Sutton worked at an ER/Critical Care facility and anesthetized a lot of high-risk patients. Then she spent a dozen years traipsing the globe, running spay and neuter clinics in less developed nations. Many of the pets on her volunteers’ spay/neuter campaigns were parasitized and malnourished pets who were “high risk” compared to the generally healthy pets we see in America. Dr. Bill Moore and Dr. Kate Raymond also come from critical care and emergency background and have also anesthetized many high-risk patients. We hope to never have to run CPR on any patient, but our core veterinarians at Tequesta Veterinary Clinic have significant experience anesthetizing high-risk patients and with resuscitative efforts, if ever needed. Keep reading to learn the many “safety nets” we have in place to minimize the risk of anesthesia. We do not allow clients to decline any of these safety nets. These are non-negotiable! These safety nets are included in the price of anesthesia. These safety nets are the things we do when we anesthetize our own pets.
We closely monitor pets under anesthesia and we try to be time-efficient when we have a pet anesthetized. Further, when Dr. Joi has your pet under anesthesia she only has ONE pet (your pet) under anesthesia at any given time. (This is unfortunately not the case at many hospitals, particularly the low-cost surgery or dental clinics.) We treat anesthesia with great respect. We have everything ready to roll prior to anesthetizing your pet. We have an IV catheter in your pet for emergency drug dosing should the heart rate slow or blood pressure drop. We utilize IV fluids for every pet under anesthesia. We monitor blood pressure, end-tidal C02 capnography, ECG, pulse oximetry, heart rate, respiratory rate, and temperature throughout the procedure. We have many “bair huggers” to keep your pet warm during the procedure and after the procedure during recovery. We utilize nerve blocks and local anesthesia in every procedure so that we can keep your pet under the lightest plane of anesthesia possible. And finally, Dr. Sutton is old and has been at this for decades. She does the majority of procedures at Tequesta Veterinary Clinic. She does not dawdle at the surgery and has a knack for dental extractions few veterinarians have. She is not a dental specialist but is pretty darned speedy. Furthermore, we have emergency drug dosages calculated before we even anesthetize a pet so that if ever a situation arises we aren’t fumbling to do math and waste time. For example: If a pet’s blood pressure drops during anesthesia we lighten the plane of anesthesia as much as possible and give a bolus of crystalloids. If that doesn’t quickly resolve the situation we can give a colloid called Hetastarch or give hypertonic saline. If that still doesn’t improve the situation we can quickly start a dopamine constant rate infusion. One of the beautiful things about a dental compared to abdominal surgery is that if we are having anesthetic complications during a dental we can finish the tooth and wake a pet up. We anesthetize pets nearly every day. We are proactive about anesthetic monitoring and respect anesthesia. Again, calculations for emergency drugs and constant rate infusions for potential concerns during anesthesia are calculated for every anesthetic patient before we anesthetize a pet. If needed, these drugs are included in the price of the procedure.
We give the pre-medication in the exam room with clients in the morning of the procedure and ask the human to wait with the pet for 15 to 20 minutes for the pre-med to take effect. This pre-med is typically a mild narcotic and some midazolam. In humans, midazolam has an “amnestic” quality, meaning folks don’t remember what happens next. We sure hope that amnestic trait translates across to our pet patients! Occasionally we might add a microdose of dexdomitor into the mix if a young pet is particularly rambunctious or anxious. Pre-meds are given under the skin and we ask the client to wait with the pet for 15 to 20 minutes prior to us taking the patient to the back for IV catheter placement. This alone decreases the stress on the pet dramatically. Additionally, we limit procedures to 2 or 3 patients per day so that pets don’t wait all day in a kennel before the procedure. If we do a 3rd procedure in a day, we typically have that client arrive at 11 am rather than at 8:30 am. Anesthesia is an art, and we strive to make the pet as relaxed as possible. Once the pet is awake and able to go home, we send the pet home rather than have it sit in a kennel and fret.
Once the pet is relaxed with the “pre-med”, we also encourage “Pre-anesthetic Global Fast Ultrasound Exams” on the day of the procedure. Much as vets have trained clients to run “pre-anesthetic bloodwork” prior to anesthesia, we now do pre-anesthetic ultrasound exams. We look at the heart, the lung surface, the kidneys and liver, the spleen, the urinary bladder, the gall bladder. Particularly for old timers, we may see incidental findings that help us ensure your pet is safe for anesthesia and help guide us to future wellness care. Or, an ultrasound may help us investigate laboratory abnormalities we’ve found on the pre-anesthetic bloodwork. We charge a nominal $115 for the pre-anesthetic global fast exam which are performed by Dr Joi or Dr Kate. The pre-anesthetic global fast exam is optional, but we encourage it for middle aged and older pets. If a pet has a heart murmur, we encourage a heart ultrasound (aka “echo”) prior to anesthesia.
Once we have everything ready to roll for the procedure, we give an “induction” agent: either Alfaxan or Propofol IV. These medications have amongst the lowest cardiac and respiratory depression of any induction agents and are very quickly out of the body. We give these meds IV slowly over 1 to 2 minutes to effect until the pet’s relaxed enough that we can place a sterile tube into the trachea (windpipe). Thereafter we maintain the pet on “gas” anesthesia and oxygen. When a pet is under gas anesthesia we have quick control of the depth of anesthesia. Obviously, we keep a pet on as light of a plane of anesthesia as possible. Nerve blocks to numb the surgical or dental site help us keep a pet under the lightest plane of anesthesia possible.
What if your pet has HEART DISEASE or is otherwise a fragile high risk anesthetic candidate? We have one more trick up our sleeve when we have a high risk patient. For the vast majority of patients we use isoflurane and oxygen to maintain anesthesia. Gas anesthesia offers fast control of how “deep” or how “light” a pet is under anesthesia. We offer both isoflurane and sevoflurane at Tequesta Vet Clinic. Sevoflurane is less soluble in the bloodstream than isoflurane. Isoflurane is quickly out of the system when we turn it off. Sevoflurane is out of the system even more quickly than isoflurane. Additionally, sevoflurane has very minimal respiratory depression. IF WE HAVE A PET WITH SIGNIFICANT HEART DISEASE WE ENCOURAGE SEVOFLUORANE. Sevoflurane is 7 to 8 times more expensive than isoflurane, so if we use sevoflurane we upcharge the anesthesia by a mere $100—We are essentially passing the added cost onto you without marking it up. Dr Sutton does a lot of dental procedures on senior pets with heart disease and wants sevoflurane for these patients. For these heart patients she gets nerve blocks in place as soon as as the pet is anesthetized and keep the patient on an extremely light plane of anesthesia! (We always use local anesthesia, but for heart patients we get the local anesthetic in place as soon as the pet is anesthetized, essentially at the same time as the nurses are attaching the anesthetic monitors.)
We are proud to be one of the 15% of veterinary clinics in America that is AAHA accredited. This means we let the inspectors come through every 2 years to evaluate our standards of care, our facility, our practices, and so on. When Dr. Sutton first got certified the AAHA inspector commented to her that Tequesta Veterinary Clinic was the fastest approval she had done in her 12 years of doing AAHA inspections. (When Dr. Sutton says she is Type A, she means it!) When clients are anxious about anesthesia, Dr. Sutton is happy to discuss our protocols and give the client a tour of our facility. We LOVE clients who want the best for their pets and are involved in the pet’s medical choices. We are never offended by clients who question our protocols or wish to have a tour of our hospital. AAHA just came out with a 2020 AAHA Anesthesia Guidelines. Clients can find AAHA 2020 Anesthesia Guidelines with a simple Google search. Know that we pride ourselves on our anesthesia protocols.
Dr. Sutton incorporates local anesthesia into nearly all of her procedures for your pet’s safety and comfort. Nerve blocks are particularly important as they allow us to keep a pet on a very light plane of anesthesia. A light plane of anesthesia helps keep the pet’s blood pressure normal under anesthesia and helps the pet maintain body temperature. Additionally, nerve blocks provide post-op analgesia. Dr. Joi uses bupivicaine which typically lasts at least 6 hours. She adds in buprenorphine to her dental nerve blocks which triples the duration of local anesthesia post-dental extraction. She gets nerve blocks in early to keep your pet from being in pain. Dental nerve blocks are FREE. Local anesthesia (bupivicaine splashes) into soft tissue surgery is FREE. If we use Nocita (a 72-hour local anesthetic) it is $140. We love Nocita, but it is extremely expensive.
In 2016 Dr. Sutton began giving every patient that undergoes anesthesia an IV injection of Cerenia at the start of general anesthesia. Cerenia is a potent 24-hour anti-nausea medication for dogs and cats. Since starting this, the incidence of perioperative inappetence and nausea has plummeted. It’s now quite rare for a pet to not eat the evening of surgery or anesthesia at Tequesta Veterinary Clinic. In 2016 Dr. Sutton heard that many human patients are more worried about nausea post-op than anesthesia itself. This hit a chord with her as each time she herself has been anesthetized she has vomited post-op. Every patient receives an IV injection of this anti-nausea medication for $25, essentially at cost.
We’ve recently added new “habits” as we wish to incorporate the use of pre-operative oral meds for our patients, particularly our senior patients. Oral melatonin is a good pre-op sedative with no side effects that have been shown to decrease stress and lower anesthetic requirements for pets. Additionally, they sleep better the night before surgery. Melatonin is particularly helpful for “skeptical” patients who get anxious in the clinic environment. Middle-aged to senior and anxious pets will get melatonin pre-op (the night before) and the night post-op. Older pets don’t get back to a normal sleeping pattern as well as the typical young pet. Old pets have a lower melatonin surge in the evening compared to young pets. We also send a dose of pantoprazole (aka Protonix) for clients to give the night before to quell the tummy upset that can occur with anesthetics. Finally, we send a dose of gabapentin for clients to give the morning of anesthesia, a couple of hours before arrival at the clinic. These are all at NO CHARGE to clients. We wish to always stay at the forefront of anesthesia and best practices to keep your sweetie as safe and comfortable as possible.
Finally, Dr. Sutton rarely is more than 10 steps away from a pet under anesthesia. Many hospitals will schedule appointments for doctors during that doctor’s dental procedures. If Dr. Sutton is doing procedures (as she does Monday through Friday each morning), you won’t likely find her at the front of the building. She will be in the back if a pet is under anesthesia. Dr. Sutton sees appointments in the afternoon or once her surgeries and dentals are completed. We treat anesthesia with the respect it deserves.